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 480559088 Hays Medical Center Inc HAYS 7856235000 2220 Canterbury Drive Hays KS 67601 John Jeter 7856235000 2012-05-14 1 Gary D Knoll 7852334226 2012-05-14 2010 2016-02-24 21:20:13Z John Jeter 2220 Canterbury Drive Hays KS 67601 194388104 0 X www.haysmed.com X 1944 KS Hays Medical Center 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 facilities 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 Organization is to help people be healthy. The Corporation is striving to become the best tertiary care center in rural America. 14 9 1598 230 2538 0 697482 105703 181500860 189610055 2251997 3355351 517536 1162575 184967875 194233684 0 0 0 0 87778078 88224901 0 0 0 87812824 96973972 175590902 185198873 9376973 9034811 192482750 242206552 71594488 101317411 120888262 140889141 X Hays Medical Center 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 facilities 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 Organization is to help people be healthy. The Corporation is striving to become the best tertiary care center in rural America. 0 0 160771811 178947941 Patient Care Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as defined in Section 501(c)(3) of the IRS code. Admissions: Acute-5,012, Newborn ICU-37, Newborn-683, Rehabilitation-153, Total admissions-5,885. Patient days: ICU/CPCU-6,509, Medical/Surgical-13,615, Oncology-1,759, Obstetrics-1,821, Pediatrics-292, Rehabilitation-1,634, Newborn ICU-332, Newborn-1,268, Total patient days-27,230. Other statistical information: Surgical procedures-7,757, Cardiac caths-930, Emergency room visits-13,439, Outpatient procedures-135.589, Medical oncology service visits-9,101, Clinic visits-139,039. 160771811 1 1 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 152 0 1 1598 1 1 1 0 0 0 0 0 0 0 0 0 X 14 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X William Overbey CFO 7856235000 2220 Canterbury Drive Hays KS 67601 Nancy Curtis 0.00 X X 0 0 0 Dennis Bieker 0.00 X X 0 0 0 Kenneth Beran 0.00 X X 0 0 0 Darrell Werth 40.00 X X 708655 0 41717 Daniel Schippers 0.00 X 0 0 0 Tom McDonald MD 0.00 X 0 0 0 Jim Black DO 0.00 X 0 0 0 Gary Shorman 0.00 X 0 0 0 John Lloyd MD 40.00 X X 486030 0 43017 Ross Buckles DO 40.00 X X 334829 0 39785 Jayne Clarke 0.00 X 0 0 0 Sharon Dreher 0.00 X 0 0 0 Alan Moore 0.00 X 0 0 0 DG Bickle 0.00 X 0 0 0 Dr Kurt Rider 40.00 X X 237807 0 38012 Joel Fort MD 40.00 X X 609966 0 40017 John Jeter MD 40.00 X 593274 0 142269 William Overbey 40.00 X 277120 0 84847 Dale Montgomery 40.00 X 181126 0 64998 Jodi Schmidt 40.00 X 164271 0 49582 Bryce Young 40.00 X 279750 0 85301 D Bruce Whittington 40.00 X 174246 0 63338 Kenneth Lindsey 40.00 X 370911 0 94260 Christine Fisher 40.00 X 1229245 0 40017 Alex De Carvalho 40.00 X 984664 0 40017 Jeffery Curtis 40.00 X 838831 0 40017 Robert Bassett 40.00 X 747278 0 40017 Babar Ali 40.00 X 707195 0 40017 January Fields-Meehan 40.00 X 604794 0 45017 Richard Rajewski MD 40.00 X 185669 0 39639 9715661 0 1071884 98 1 1 0 Quest Diagnostics Inc PO Box 14730 St Louis MO 631504730 Lab Services 4650640 Inpatient Management Inc 1 McBride and Son Center Dr Suite Chesterfield MO 63005 Hospitalists Program 1442242 Anesthesiologist Associates of Hays PO Box 821 Hays KS 67601 Anesthesia Services 1221864 Comphealth PO Box 972651 Dallas TX 75397 Physician Coverage 990461 Manmohan Biring MD 1582 Charlton Road San Marino CA 91108 Pulmonology Services 865806 27 58478 47225 105703 Net patient service re 621990 178947941 178947941 Shared services 900099 8492468 8492468 Other operating revenu 900099 2167108 2167108 Nursing mother's resou 446199 2538 2538 189610055 3493571 3493571 16200 154420 -138220 -138220 -138220 Equity in gain of Hadl 900099 1162575 1162575 1162575 194233684 178947941 2538 15177502 5089233 2541978 2547255 67198088 58802913 8395175 3154449 2676947 477502 8285572 6610362 1675210 4497559 3816745 680814 150185 150185 517910 517910 106587 106587 157620 157620 20403287 18123392 2279895 481233 372194 109039 1363671 818203 545468 2099974 1650780 449194 272265 194790 77475 818092 543622 274470 2899603 2899603 10390872 8467945 1922927 1286817 1040883 245934 Supplies 34426535 34063242 363293 Bad debts 12249562 12249562 Repairs & maintenance 3466042 3088858 377184 Rent 2248751 1814454 434297 Taxes & assessments 970287 970287 2664679 995338 1669341 185198873 160771811 24427062 0 5885 6185 9397817 5003500 27864083 31647122 3910829 4191623 3392473 3918946 177553229 114345881 63682783 63207348 0 104984451 598000 84228880 28649377 192482750 242206552 19744488 20244515 51850000 80229741 843155 71594488 101317411 X 115118946 133957250 5769316 6931891 120888262 140889141 192482750 242206552 X 9034811 10966068 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9112302 196718 290058 82450 9516628 8603284 332063 234201 0 57246 0 9112302 8152895 249859 226379 0 25849 0 8603284 0.65600 0.31600 0.02800 0 1 1 350356 350356 56596581 29232905 27363676 108910924 80964770 27946154 11695368 4148206 7547162 63207348 Hedge funds 6758682 F U S Government and agency obligations 5297023 F U S Government and agency obligations 26696589 F Corporate bonds 6595620 F Equity investments 55225003 F Commodity mutual fund 4411534 F 104984451 Cash whose use is limited by Board or indenture agreement 13810163 Interest receivable whose use is limited by Board or indenture agreement 283003 Interest in net assets of Hadley Foundation 6931891 Other receivables 2197303 Debt issue costs 1015220 Other long-term assets 4411797 28649377 194233684 185198873 9034811 10966068 10966068 20000879 Description of Intended Use of Endowment Funds: Part V, Line 4: The endowed funds held by the Hays Medical Center Foundation are used to help meet both the immediate and long range health care needs of patients of Hays Medical Center, Inc.. The Hays Medical Center Foundation provides grants and assistance to Hays Medical Center, Inc. for property and equipment acquisitions, education, and community health issues. 1 1 X 1 X 125.000000000000 1 X 1 1 0 1 1 2073813 2073813 0.01200 9028140 6458591 2569549 0.01490 11101953 6458591 4643362 0.02690 1873303 1573891 299412 0.00170 661706 661706 0.00380 47823989 39710010 8113979 0.04690 12677 12677 0.00010 50371675 41283901 9087774 0.05250 61473628 47742492 13731136 0.07940 82500 82500 0.00050 82500 82500 0.00050 0 3565847 249609 61774944 62806234 -1031290 X 1 1 2 1 Hays Medical Center Inc

2220 Canterbuty Hays KS 67601

X X X 2 Pawnee Valley Community Hospital Inc

923 Carroll Ave Larned KS 67550

X X X X Hays Medical Center 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 Pawnee Valley Community Hospital Inc 2 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 5 Hays Family Medicine

2509 Canterbury Hays KS 67601

Family Medicine Pawnee Valley Medical Associates

713 W 11th St Larned KS 67550

Family Medicine Central Kansas Urology

353 W 10th St Hoisington KS 67544

Urology Services HaysMed Psychiatric Associates

205 E 7th St Hays KS 67601

Psychiatric Services Breast Care Center

2501 E 13th St Hays KS 67601

Breast Care Services Part I, Line 7: Hays Medical Center, Inc.'s 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, Line 7g: Physician clinic net costs included in subsidized health services totaled $6,005,704. Part I, L7 Col(f): Bad debt expense of $12,249,564 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 II: Hays Medical Center, Inc. helps to support the First Care Clinic in Hays, Kansas. This clinic was established to help lower income individuals receive health care at a reduced cost. This support helps to increase the number of individuals in Hays, Kansas who receive quality health care. Part III, Line 4: Footnote text: 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.Costing methodology: Bad debt expense at cost was estimated using an overall cost-to-charge ratio multiplied by the provision for bad debts.Methodology for bad debt cost for financial assistance eligible: This amount was estimated based on historical information from our collection agency on the percentage of accounts referred to collection whose guarantor was indigent. 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 Hays Medical Center, Inc. Medicare cost report for fiscal year ended June 30, 2011. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Hays Medical Center, Inc. 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 within 30 days, the CSR contacts the patient. If it is determined that at least a 2 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 11h: Pawnee Valley Community, 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. Hays Medical Center, Inc. Part V, Section B, Line 13g: Hays Medical Center will proactively seek out applicants who may be in need of financial assistance. Hays Medical Center 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 Hays Medical Center, 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 of Hays Medical Center, Inc. contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify the Hospitals charity care policy, they will send the application to the patient as well. Part VI, Line 4: Hays Medical Center, Inc. is located in Hays, Kansas, which has a population of approximately 20,000 people, as of the 2010 census. One of the State of Kansas Regents universities is also located in Hays, Kansas, so the population includes many college-aged students. The median household income of Hays, Kansas is $44,227. Approximately 5.7% of families and 15.6% of the population were below the poverty line. Just over 5% of the hospitals revenue is from services provided to patients eligible for Medicaid. Hays Medical Center, Inc. is the only hospital in the city of Hays. In addition, since this is a rural area and because it is the only hospital providing tertiary level care in the region, Hays Medical Center, Inc. provides certain services to the whole western half of the State of Kansas. Part VI, Line 6: Hays Medical Center, Inc. promotes the health of the community by extending medical privileges to most qualified, local physicians. In addition, the majority of the Board of Directors live and work in the city of Hays, but they are not employed by Hays Medical Center. Inc. Part VI, Line 7: Hays Medical Center, Inc. is not a part of an affiliated health care system. X X 1 1 X X X X 0 1 0 0 0 1 0 0 0 Darrell Werth 598300 0 90063 0 20292 0 13475 0 28242 0 750372 0 359537 0 John Lloyd MD 322000 0 150251 0 13779 0 13475 0 29542 0 529047 0 260298 0 Ross Buckles DO 200000 0 131618 0 3211 0 13475 0 26310 0 374614 0 169289 0 Dr Kurt Rider 227000 0 0 0 10807 0 8470 0 29542 0 275819 0 121000 0 Joel Fort MD 350000 0 259193 0 773 0 13475 0 26542 0 649983 0 333223 0 John Jeter MD 400726 0 166740 0 25808 0 115727 0 26542 0 735543 0 209673 0 William Overbey 210672 0 63150 0 3298 0 55537 0 29310 0 361967 0 105250 0 Dale Montgomery 136914 0 31801 0 12411 0 36209 0 28789 0 246124 0 79104 0 Jodi Schmidt 109054 0 35190 0 20027 0 32390 0 17192 0 213853 0 77053 0 Bryce Young 212055 0 63120 0 4575 0 55991 0 29310 0 365051 0 105200 0 D Bruce Whittington 130594 0 28214 0 15438 0 35549 0 27789 0 237584 0 67675 0 Kenneth Lindsey 275139 0 81120 0 14652 0 67718 0 26542 0 465171 0 0 0 Christine Fisher 600000 0 595822 0 33423 0 13475 0 26542 0 1269262 0 605564 0 Alex De Carvalho 500000 0 470564 0 14100 0 13475 0 26542 0 1024681 0 424687 0 Jeffery Curtis 409385 0 411283 0 18163 0 13475 0 26542 0 878848 0 361438 0 Robert Bassett 500000 0 240778 0 6500 0 13475 0 26542 0 787295 0 368134 0 Babar Ali 533209 0 130392 0 43594 0 13475 0 26542 0 747212 0 331628 0 January Fields-Meehan 523462 0 0 0 81332 0 13475 0 31542 0 649811 0 334662 0 Richard Rajewski MD 172000 0 11724 0 1945 0 10329 0 29310 0 225308 0 97244 0 Part I, Line 1a Benefits identified include tax indemnification on health claims and health club dues. Both benefits are available to the CEO and are included in taxable income. Part I, Line 4b Officers and key employees are eligible to participate in a 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 on Schedule J as a component of deferred compensation. Contribution amounts for listed persons for FYE 6-30-11 were: officers - $331,403, key employees - $130,088. Part I, Line 6 A portion of incentive compensation for officers and key employees is determined by net earnings exceeding budget for the fiscal year. Kansas Development Finance Authority 481066589 48543BGR3 2003-11-12 16000878 Construction 0 0 0 Kansas Development Finance Authority 481066589 48543BJD1 2005-11-22 23635944 Construction 0 0 0 Kansas Development Finance Authority 481066589 48543BLY2 2010-11-02 46930167 Refinancing of previous bond and equipment 0 0 0 16665728 1200024 726489 15939215 2005 0 0 1 1 23635944 2023250 316000 23319944 2006 0 1 1 1 16300000 29952593 667574 29962593 2012 0 1 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Blue Cross Blue Shield Gary Shorman is a director on both HMC's and Blue Cross Blue Shield's Board 56600000 The insurance reimbursements received by Hays Medical Center, Inc. from Blue Cross Blue Shield of Kansas only represents approximately 2.75% of Blue Cross Blue Sheild's annual disbursements. 0 Eagle Communications Gary Shorman is CEO of Eagle Communications and on the Board of HMC 121177 Payments for cable/internet 0 Jeter Law Firm Family member of John Jeter, CEO of HMC 6112 Payments for legal services 0 John Jeter Board President and CEO Board President, Pawnee Valley Community Hospital, Inc. 0 N/A 0 Bryce Young COO Hays Medical Cent Board Vice-President Pawnee Valley Community Hospital, Inc. 0 N/A 0 William Overbey CFO Hays Medical Board Sec/Treas Pawnee Valley Community Hospital, Inc. 0 N/A 0 Shea Veach Director of Regional Op Board Member, Pawnee Valley Community Hospital, Inc. 0 N/A 0 D G Bickle Board Member Hays Me D. G. Bickle, Brother of Lynette Pfannenstiel, employee of HMC 0 N/A 0 Lynette Pfannenstiel employee Resp Lynette Pfannenstiel, Sister of D. G. Bickle, Board Member of HMC 72238 Employee wages 0 Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the officers and Board Finance committee. Form 990, Part VI, Section B, line 12c Officers, directors, and 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 CEO, officers and key employees salaries are reviewed annually by an independent consulting group and the Compensation Committee, which is made up of members of the Board. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Financial statements are released to bond holders on a quarterly basis. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 10,966,068. 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 financial statement audit and the selection process of an independent accountant Hays Medical Center Foundation 2220 Canterbury Hays KS 67601 481179684 Provide grants and allocations to Hays Medical Center, Inc. KS 501(c)(3) Line 11a, I 0 HaysMed Partners Inc 2220 Canterbury Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) Line 3 Hays Medical Center Inc 0 Pawnee Valley Community Hospital Inc 2220 Canterbury Hays KS 67601 481253246 Hospital operated by Hays Medical Center KS 501(c)(3) Line 3 0 0 0 1 1 0 1 0 0 0 1 1 0 0 1 0 0 0 0 Hays Medical Center Foundation C 58478 Hays Medical Center Foundation P 198925 Pawnee Valley Community Hospital Inc D 57169 Pawnee Valley Community Hospital Inc K 485309 Pawnee Valley Community Hospital Inc N 92600 Pawnee Valley Community Hospital Inc F 1000 Pawnee Valley Community Hospital Inc J 77803