2012-05-15T13:55:32-05:00 2011-06-30 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2010-07-01 810231787 NORTHERN MONTANA HOSPITAL NORT 4062652211 PO BOX 1231 HAVRE MT 595011231 DAVID HENRY 4062652211 2012-05-15 1 KIM C HUNWARDSEN 6122536500 2012-05-15 2010 2016-02-24 21:20:13Z DAVID HENRY PO BOX 1231 HAVRE MT 595011231 67986721 0 X WWW.NMHCARE.ORG X 1921 MT PROVISION OF HEALTHCARE SERVICES. 12 7 762 115 431496 0 371041 237879 52416962 52974508 452871 922805 12056 11540 53252930 54146732 8909 9152 0 0 28161270 28598427 0 0 0 23362441 22385565 51532620 50993144 1720310 3153588 50643440 53915880 11345455 9021711 39297985 44894169 X TO DELIVER HIGH QUALITY COMPREHENSIVE HEALTH CARE SERVICES TO THE HI-LINE COMMUNITIES. 1 1 38146336 52543012 NORTHERN MONTANA HOSPITAL (HOSPITAL) PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION TO ALL COMMUNITY MEMBERS. DURING THE YEAR ENDED JUNE 30, 2011, THE HOSPITAL PROVIDED $1,262,053 OF MEDICAL SERVICES, BASED ON CHARGES, TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE OF PROVIDING CARE TO THESE PATIENTS WAS $27,645,331 FOR THE YEAR ENDED JUNE 30, 2011. DURING THE FISCAL YEAR ENDED JUNE 30, 2011 THE HOSPITAL PROVIDED OVER 5,000 DAYS OF HOSPITAL SERVICES. THE NURSING HOME PROVIDED OVER 39,000 DAYS OF RESIDENT SERVICES DURING THE YEAR.THE HOSPITAL ALSO PROVIDES COMMUNITY CARE AND SERVICES THROUGH MANY HEALTH CARE ACTIVITIES AND PROGRAMS PROVIDED TO SUPPORT THE COMMUNITY. THESE ACTIVITIES INCLUDE: WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SENIOR SERVICES, HEALTH CARE SCREENING, SPECIAL PROGRAMS FOR SPECIFIC GROUPS, PUBLISHED ARTICLES, RADIO PROGRAMS, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. THE HOSPITAL ALSO RECEIVED MANY HOURS OF VOLUNTEER HELP FROM THE COMMUNITY RESIDENTS. 38146336 1 1 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 103 0 1 762 1 1 1 0 0 0 0 0 0 0 0 0 X 12 7 0 1 0 0 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X KIM LUCKE VP OF FINANCE 4062652211 PO BOX 1231 HAVRE MT 59501 DAVID C HENRY 40.00 X X 347250 0 0 DAVID LEEDS 1.00 X X 0 0 0 JUDY GREENWOOD 1.00 X X 0 0 0 MILES HAMILTON 1.00 X X 0 0 0 BRUCE RICHARDSON MD 40.00 X X 322727 0 18229 PAUL TUSS 1.00 X 0 0 0 STEPHEN BECHDOLT MD 40.00 X 277266 0 11019 TOM PATRICK 1.00 X 0 0 0 ANDREW CARLSON 1.00 X 0 0 0 MARGARET DOW MD 40.00 X 206109 0 22828 MICHAEL NOLAN MD 40.00 X 256158 0 3048 JULIE HOLT 1.00 X 0 0 0 KAREN POLLINGTON 40.00 X 91011 0 18417 KIM LUCKE 40.00 X 70551 0 15318 JOEL CLEARY MD 40.00 X 345808 0 1386 KAREN E LIEN MD 40.00 X 319656 0 20779 JOHN TRUE MD 40.00 X 352286 0 0 SHAHRIAR ANOUSHFAR MD 40.00 X 374225 0 7844 SUZANNE SWIETNICKI MD 40.00 X 243861 0 21321 3206908 0 140189 34 0 1 0 MARK A WARD DO 120 W 30TH STREET HAVRE MT 59501 CONTRACT PHYSICIAN SERVICES 360926 MERIDIAN MEDICAL STAFFING 26 W DRYCREEK CIRCLE SUITE 600 LITTLETON CO 80120 NURSING STAFFING 329209 DANIEL ABBOTT 1715 13TH STREET WEST HAVRE MT 59501 ANESTHESIA SERVICES 327482 PHILIPS MEDICAL SYSTEMS 22100 BOTHELL EVERETT HIGHWAY BOTHELL WA 98041 MAINTENANCE SERVICES 281077 LISTON RADIOLOGY CONSULTING 1562 RIALTO LANE DAVIS CA 95618 CONTRACT RADIOLOGY SERVICES 240142 13 185110 19600 33169 10110 237879 NET PATIENT SERVICE RE 622110 46076753 46076753 PHARMACY 446110 6150287 5718791 431496 HEALTHCARE CONSULTING 541900 418151 418151 CAFETERIA REVENUE 722210 232285 232285 OTHER PROGRAM REVENUE 900099 97032 97032 52974508 786666 786666 11040 500 11040 500 11540 11540 13915824 60304 13813934 26055 101890 34249 136139 136139 54146732 52543012 431496 934345 9152 9152 1934630 1348827 585803 22256367 15579457 6676910 865492 564871 300621 1541966 910775 631191 1999972 1399980 599992 291000 58200 232800 35938 35938 70364 70364 4661347 4385316 276031 342434 342434 6931881 5892099 1039782 428241 342593 85648 1749351 1224546 524805 214903 75216 139687 103 103 1845555 1291889 553666 1324169 1059335 264834 BAD DEBT EXPENSE 2903633 2903633 EQUIPMENT RENTAL AND MA 843180 463749 379431 BED TAX 610006 610006 133460 26692 106768 50993144 38146336 12846808 0 4475278 5390345 936844 287849 10620214 11385437 1378066 1319273 391380 713310 46181805 37552627 9073946 8629178 20135368 25350329 3327184 90226 305160 749933 50643440 53915880 4392924 3759420 6952531 5262291 11345455 9021711 X 39297985 44894169 39297985 44894169 50643440 53915880 X 3153588 2442596 X X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 30662 104037 102290 32409 0 75272 75272 19732336 15819824 3912512 25159741 21052301 4107440 1214456 680502 533954 8629178 LIABILITY FOR PENSION BENEFITS 4499593 THIRD-PARTY PAYOR SETTLEMENTS 762698 5262291 PART IV, LINE 1B: PART IV, LINE 1B: THE CUSTODIAL FUNDS ARE NOT REPORTED ON THE BALANCE SHEET OF NMH AS THEY ARE THE PERSONAL RESOURCE FUNDS OF THE RESIDENTS TO BE USED ONLY FOR THEIR PERSONAL NEEDS. IF THE RESIDENT PASSES, THE FUNDS EITHER GO TO THE FAMILY OR BACK TO THE STATE. THEY ARE IN NO WAY AN ASSET OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: PART X, LINE 2: THE ORGANIZATION UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES. AS OF JUNE 30, 2011 AND 2010, THE UNRECOGNIZED TAX BENEFIT ACCRUAL IS ZERO. 1 1 X 1 X 1 X 1 1 0 1 1 734257 734257 0.01530 10991865 10127417 864448 0.01800 238133 266297 -28164 0.00000 11964255 10393714 1570541 0.03330 12667 7728 7728 0.00020 160 20532 20532 0.00040 10335 7944322 6358942 1585380 0.03300 0 3626 23226 23226 0.00050 26788 7995808 6358942 1636866 0.03410 26788 19960063 16752656 3207407 0.06740 3780 7427 7427 0.00020 163 1796 1796 0.00000 1342 861 861 0.00000 44 1950 1950 0.00000 5329 12034 12034 0.00020 0 1689321 26327 8963871 9206903 -243032 X 0 1 1 NORTHERN MONTANA HOSPITAL

30 13TH STREET HAVRE MT 59501

X X X NA 1 3 NORTHERN MONTANA MEDICAL GROUP WEST

20 13TH STREET WEST HAVRE MT 59501

CLINIC NORTHERN MONTANA MEDICAL GROUP EAST

124 13TH STREET HAVRE MT 59501

CLINIC NORTHERN MONTANA CARE CENTER

24 13TH STREET HAVRE MT 59501

NURSING HOME PART I, LINE 6A: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT WAS PUBLISHED AS A 1/2 PAGE AD IN THE LOCAL NEWSPAPER. IN ADDITION, A STATEMENT ABOUT THE AMOUNT OF COMMUNITY BENEFIT THE ORGANIZATION PROVIDED CAN BE FOUND ON OUR WEB-SITE AT WWW.NMHCARE.ORG. PART I, LINE 7: CHARITY CARE EXPENSE ON LINE 7A WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. UNREIMBURSED MEDICAID, LINE 7B, AND UNREIMBURSED COSTS - OTHER MEANS-TESTED GOVERNMENT PROGRAMS, LINE 7C, WERE CALCULATED USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CASH AND IN-KIND DONATIONS, LINE 7I, ARE ACTUAL COSTS REPORTED IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION WAS $2,903,633. PART II: REPORTED UNDER COMMUNITY BUILDING ACTIVITIES IS THE MAINTENANCE OF OUR FITNESS PARK. IT IS A 7 ACRE PARK WITH CONCRETE WALKING TRAILS, A SOFTBALL AND SOCCER FIELD AND IS A PLACE FOR THE COMMUNITY TO GET OUTDOORS AND EXERCISE. ALSO INCLUDED IS STORAGE OF BASKETBALL HOOPS FOR THE 3-ON-3 TOURNAMENTS THE CITY PUTS ON TO GET YOUTH OUT AND ACTIVE. MANY LEADERS OF THE ORGANIZATION SERVE ON VARIOUS BOARDS THROUGHOUT THE COMMUNITY, SUCH AS THE CHAMBER OF COMMERCE, HILL COUNTY PLANNING BOARD AND HILL COUNTY HEALTH CONSORTIUM. THROUGH THESE SERVICES, WE ARE ABLE TO KEEP ABREAST OF HEALTHCARE NEEDS IN THE COMMUNITY AND COLLABORATE WITH VARIOUS ORGANIZATIONS TO HELP MAKE IT HAPPEN. PART III, LINE 4: BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2.THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BY USING CHARITY CARE AS A PERCENTAGE OF GROSS PATIENT SERVICE REVENUE. AS A PORTION OF REVENUE IS CONSIDERED CHARITY CARE, IT IS ASSUMED THAT A PERCENTAGE OF BAD DEBT EXPENSE WOULD ALSO BE CONSIDERED CHARITY CARE.BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT 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: THESE EXPENSES REPRESENT AN OVERALL SHORTFALL OF THE MEDICARE PATIENT POPULATION. THE COSTS THEMSELVES ARE THEREFORE A COMMUNITY BENEFIT AS THE COMMUNITY WOULD NOT RECEIVE THESE SERVICES IF WE DID NOT PROVIDE THEM. 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 ORGANIZATION DOES NOT HAVE A WRITTEN DEBT COLLECTION POLICY, BUT HAVE WRITTEN PROCEDURES THAT THEY FOLLOW. THE ORGANIZATION IS WORKING ON DEVELOPING A WRITTEN DEBT COLLECTION POLICY. THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY PROVIDES HOW THEY WILL COLLECT FROM THOSE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. THE POLICY STATES "DURING THE PATIENT REGISTRATION OR COLLECTION PROCESS, THE HOSPITAL WILL MAKE AN INITIAL DETERMINATION OF ELIGIBILITY BASED ON VERBAL OR WRITTEN APPLICATION FOR CHARITY CARE. PENDING FINAL ELIGIBILITY DETERMINATION, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS, PROVIDED THAT THE RESPONSIBLE PARTY IS COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF STATUS, INCLUDING RETURN OF APPLICATIONS AND DOCUMENTATION REQUIRED BY THE HOSPITAL WITHIN FOURTEEN (14) DAYS OF RECEIPT." PART VI, LINE 2: COMMUNITY NEEDS ASSESSMENTS ARE CONDUCTED THROUGHOUT THE COMMUNITY BY ORGANIZATIONS SUCH AS HRDC, THE BOYS & GIRLS CLUB AND THE MONTANA ECONOMIC DEVELOPMENT COUNCIL. THESE ASSESSMENTS ARE SHARED WITH THE COMMUNITY. THROUGH THESE ASSESSMENTS, NORTHERN MONTANA HOSPITAL IS ABLE TO IDENTIFY THE NEEDS WE CAN HELP MEET. THE CURRENT NEEDS ARE: TRANSPORTATION, MENTAL HEALTH AND YOUTH IN NEED. NORTHERN MONTANA HOSPITAL HAS KEY EMPLOYEES THAT ARE WORKING WITH A COLLECTIVE COMMUNITY GROUP ON THE TRANSPORTATION COALITION. WE ALSO PARTICIPATE IN A COMMUNITY PROGRAM, 'HEALTHY YOUTH, HEALTHY COMMUNITY' IN COALITION WITH THE BOYS & GIRLS CLUB AND OTHER COMMUNITY ORGANIZATIONS. NORTHERN MONTANA HOSPITAL IS HELPING TO MEET THE MENTAL HEALTH NEEDS OF THE COMMUNITY BY OFFERING AND SUBSIDIZING MENTAL HEALTH SERVICES. WE ALSO SUBSIDIZE THE BULLHOOK COMMUNITY HEALTH CENTER WHICH WAS FORMED TO MEET THE NEEDS OF THE UNINSURED AND UNDERINSURED.BEGINNING IN FY 2011 NORTHERN MONTANA HOSPITAL BECAME A MEMBER OF THE HILL COUNTY HEALTH CONSORTIUM. THE CONSORTIUM IS COMPOSED OF MANY IMPORTANT STAKEHOLDERS IN OUR COMMUNITY WHO HAVE JOINED TOGETHER. WORKING TOGETHER, THE CONSORTIUM MEMBERS CONTRIBUTED A GREAT DEAL OF TIME AND RESOURCE TO COMPLETE THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE CHANGE (COMMUNITY HEALTH ASSESSMENT AND GROUP EVALUATION) TOOL FROM THE CDC WEBSITE WAS CHOSEN TO HELP US THROUGH THE PROCESS OF OUR COMMUNITY HEALTH ASSESSMENT MAINLY BECAUSE IT WOULD WALK US THROUGH EACH STEP IN THE PROCESS. CHANGE CAN BE USED TO GAIN A PICTURE OF THE POLICY, SYSTEMS, AND ENVIRONMENTAL CHANGE STRATEGIES CURRENTLY IN PLACE THROUGHOUT THE COMMUNITY; DEVELOP A COMMUNITY ACTION PLAN FOR IMPROVING POLICIES, SYSTEMS, AND THE ENVIRONMENT TO SUPPORT HEALTHY LIFESTYLES; AND ASSIST WITH PRIORITIZING COMMUNITY NEEDS AND ALLOCATING AVAILABLE RESOURCES. THE CHANGE TOOL INVOLVES DIVIDING OUR COMMUNITY INTO 5 DIFFERENT SECTORS AND CHOOSING A FEW SITES WITHIN THOSE SECTORS TO COLLECT RESPONSES FROM. THE 5 SECTORS INCLUDE:(1) COMMUNITY-AT-LARGE(2) COMMUNITY-INSTITUTIONS-ORGANIZATIONS(3) WORKSITE(4) HEALTH CARE(5) SCHOOLSALONG WITH THE CHANGE TOOL, A WRITTEN SURVEY WAS CREATED USING AN EXAMPLE FROM WILKES HEALTHY CAROLINIANS COUNCIL (WILKESHEALTH.COM). THIS SURVEY SEEMED TO FIT CLOSELY WITH OUR NEEDS, WITH ONLY MINOR ADJUSTMENTS BEING MADE TO FIT HILL COUNTY. THIS WRITTEN SURVEY WAS AVAILABLE THROUGHOUT HILL COUNTY AT VARIOUS WAITING AREAS SO PEOPLE WOULD HAVE ADEQUATE TIME TO COMPLETE THEM. PART VI, LINE 3: NORTHERN MONTANA HOSPITAL INFORMS AND EDUCATES PATIENTS ABOUT THEIR ELIGIBILITY FOR ASSISTANCE THROUGH A SIGN POSTED AT OUR ADMISSIONS DESK, NOTED IN THE BROCHURE WE GIVE PATIENTS AT OUR CLINICS, AND SIGNS POSTED AT OUR CLINIC REGISTRATION DESKS. IN ADDITION, OUR COLLECTION STAFF OFFERS CHARITY CARE AS AN OPTION WHEN THEY ARE DISCUSSING THE PATIENT'S BALANCE AS WELL AS THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS. AS OF OCT 2010, NMH HAS CONTRACTED WITH A COMPANY TO ASSIST THE PATIENT WITH QUALIFICATION FOR PROGRAMS SUCH AS MEDICAID AND DISABILITY DETERMINATION.WE ALSO PUBLISH A COMMUNITY BENEFIT REPORT ANNUALLY WHICH STATES HOW MUCH CHARITY CARE WE HAVE GIVEN AWAY, AND WE POST OUR COMMUNITY BENEFIT REPORT ON OUR WEBSITE NOTING THAT WE PROVIDE CHARITY CARE. PART VI, LINE 4: NORTHERN MONTANA HOSPITAL IS A 49 BED HOSPITAL INCLUDING 5 SWING BEDS, A 5 BED INTENSIVE CARE UNIT, EMERGENCY ROOM, SAME DAY SURGERY, AND A 6 CHAIR DIALYSIS UNIT; NORTHERN MONTANA CARE CENTER, A 136 BED SKILLED AND INTERMEDIATE CARE FACILITY OF WHICH 20 BEDS ARE DESIGNATED FOR RESIDENT'S WITH ALZHEIMER'S DISEASE AND OTHER RELATED DEMENTIAS; NORTHERN MONTANA ASSISTED LIVING, A 10 BED FACILITY; NORTHERN MONTANA MEDICAL GROUP - EAST, A RURAL HEALTH CLINIC; NORTHERN MONTANA MEDICAL GROUP - WEST, A RURAL HEALTH CLINIC; NORTHERN MONTANA VISION CENTER, AN OPHTHALMOLOGY OFFICE; NORTHERN MONTANA HOME MEDICAL EQUIPMENT (OPERATIONS DISCONTINUED 12/31/2010), BEAR PAW HOSPICE, AND THE HI-LINE SLEEP CENTER. THE HOSPITAL'S SERVICE AREA CONSISTS OF HILL, BLAINE, LIBERTY, PHILIPS AND THE BIG SANDY CENSUS DISTRICT OF CHOTEAU COUNTIES. THE POPULATION OF THIS SERVICE AREA IS APPROXIMATELY 30,000. THE MEDIAN HOUSEHOLD INCOME IS ABOUT $37,000. APPROXIMATELY 45% OF THE POPULATION HAS A HOUSEHOLD INCOME BELOW 200% OF THE FEDERAL POVERTY GUIDELINES. APPROXIMATELY 23% OF THE POPULATION IS COVERED BY MEDICAID, 30% BY MEDICARE, 2.41% BY CHIP AND ABOUT 10.4% UNINSURED. ADDITIONALLY, ANOTHER 8% OF THE POPULATION IS COVERED BY INDIAN HEALTH SERVICES. THE ENTIRE SERVICE AREA IS CONSIDERED RURAL AND HAS BEEN DESIGNATED A HEALTH PROFESSIONAL SHORTAGE AREA FOR ALL PRIMARY MEDICAL CARE, MENTAL HEALTH AND DENTAL. IN ADDITION, THE ENTIRE SERVICE AREA IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA. NORTHERN MONTANA HOSPITAL IS THE ONLY LOCAL HOSPITAL IN ITS SERVICE AREA, HOWEVER THERE ARE 3 CRITICAL ACCESS HOSPITALS, 4 RURAL HEALTH CLINICS, 3 COMMUNITY HEALTH CLINICS AND 3 IHS-TRIBAL CLINICS WITHIN ITS SERVICE AREA. THE NEAREST HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND IS 35 MILES AWAY. PART VI, LINE 6: NORTHERN MONTANA HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY. THE ORGANIZATION APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE BY KEEPING ITS MEDICAL EQUIPMENT UP TO DATE, SENDING ITS EMPLOYED PHYSICIANS FOR FURTHER CONTINUING EDUCATION, SUPPORTING NURSING EDUCATION THROUGH A LOAN RE-PAYMENT ASSISTANCE PROGRAM AND SUPPORTING HEALTH CARE EDUCATION THROUGH AN EDUCATION ASSISTANCE PROGRAM. IN ADDITION, THE HOSPITAL SUBSIDIZES ITS EMERGENCY DEPARTMENT BY OFFERING 24/7 EMERGENT CARE COVERAGE TO ALL, REGARDLESS OF THEIR ABILITY TO PAY. NORTHERN MONTANA HOSPITAL ALSO PARTICIPATES IN ALL GOVERNMENT SPONSORED HEALTH PROGRAMS, SUCH AS CHIP, HEALTHY MONTANA KIDS AND THE MONTANA CERVICAL AND BREAST CANCER PROGRAM, WHERE IT ACCEPTS PAYMENTS FOR SERVICES AT GREATLY DISCOUNTED RATES. SEVERAL MEMBERS OF NORTHERN MONTANA HOSPITAL'S LEADERSHIP TEAM SERVE ON OTHER COMMUNITY BOARDS, SUCH AS: HAVRE CHAMBER OF COMMERCE, HILL COUNTY HEALTH CONSORTIUM, LOCAL EMERGENCY PLANNING, FETAL/INFANT/CHILD MORTALITY REVIEW BOARD, HAVRE/HILL COUNTY PLANNING BOARD, HILL AND BLAINE COUNTY ADULT PROTECTIVE SERVICES COMMITTEE, HILL COUNTY UNITED WAY, HRDC MEDICAL ADVISORY BOARD, MSU-N NURSING ADVISORY BOARD AND THE SAFE KIDS SAFE COMMUNITIES COMMITTEE. PART VI, LINE 7: N/A REPORTS FILED WITH STATES PART VI, LINE 7 MT 1 EDUCATION ASSISTANCE 5 9152 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES EDUCATION ASSISTANCE TO QUALIFIED EMPLOYEES. THE ORGANIZATION MONITORS THE USE OF THE ASSISTANCE BY DISBURSING THE FUNDS DIRECTLY TO THE INSTITUTION. THE ORGANIZATION ALSO PROVIDES SUPPORT TO A RELATED TAX-EXEMPT ORGANIZATION IN SUPPORT OF THEIR EXEMPT PURPOSE. OTHER INFORMATION: PART IV: PER OUR EDUCATION ASSISTANCE POLICY, WE WILL ONLY ASSIST FOR DEGREES THAT WILL FULFILL OUR STAFFING NEEDS. WE WILL PAY UP TO $5,250 PER EMPLOYEE PER YEAR, HOWEVER NOT EVERY APPLICANT REQUESTS THE FULL AMOUNT. THEREFORE, WE ANTIPATE 3-6 RECIPIENTS PER YEAR. X X X X 0 0 0 1 0 0 0 0 0 DAVID C HENRY 275250 0 72000 0 0 0 0 0 0 0 347250 0 0 0 BRUCE RICHARDSON MD 321539 0 0 0 1188 0 0 0 21131 0 343858 0 0 0 STEPHEN BECHDOLT MD 276078 0 0 0 1188 0 0 0 13474 0 290740 0 0 0 MARGARET DOW MD 205941 0 0 0 168 0 0 0 24756 0 230865 0 0 0 MICHAEL NOLAN MD 254970 0 0 0 1188 0 0 0 5310 0 261468 0 0 0 JOEL CLEARY MD 345098 0 0 0 710 0 0 0 4424 0 350232 0 0 0 KAREN E LIEN MD 319446 0 0 0 210 0 0 0 23685 0 343341 0 0 0 JOHN TRUE MD 350000 0 0 0 2286 0 0 0 3068 0 355354 0 0 0 SHAHRIAR ANOUSHFAR MD 348341 0 0 0 25884 0 0 0 10921 0 385146 0 0 0 SUZANNE SWIETNICKI MD 243447 0 0 0 414 0 0 0 23565 0 267426 0 0 0 PART I, LINE 5 PART I, LINE 5: TWO PHYSICIANS LISTED IN PART VII OF THE FORM 990 ARE COMPENSATED AS A PERCENTAGE OF THE PRIOR THREE MONTHS' AVERAGE GROSS REVENUE EARNED FOR THE HOSPITAL BY THE PHYSICIAN, WITH THE PERCENTAGE BEING BASED ON THEIR SPECIALTY. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 3: THE CEO/PRESIDENT OF NORTHERN MONTANA HOSPITAL IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, FUNDAMENTAL FINANCIAL GROUP, FOR HIS SERVICES PROVIDED TO NORTHERN MONTANA HOSPITAL, NORTHERN MONTANA HEALTH CARE FOUNDATION, INC., AND NORTHERN MONTANA HEALTH CARE, INC. HE SERVES 40 HOURS PER WEEK AT THE HOSPITAL, TWO (2) HOURS PER WEEK AT THE FOUNDATION, AND ONE (1) HOUR PER WEEK AT NORTHERN MONTANA HEALTH CARE, INC. THE BOARD WORKS WITH THE UNRELATED MANAGEMENT COMPANY TO DETERMINE THE CEO/PRESIDENT'S COMPENSATION USING THE METHODS CHECKED IN LINE 3. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 VISITING NURSE SERVICES AVAILABLE JULY 1, 2010. CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 HOME HEALTH CARE CLOSED JUNE 30, 2010 AND HOME MEDICAL EQUIPMENT CLOSED DECEMBER 31, 2010. FORM 990, PART VI, SECTION A, LINE 3 THE PRESIDENT/CEO OF THE HOSPITAL IS EMPLOYED BY AN UNRELATED MANAGEMENT COMPANY. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS NORTHERN MONTANA HEALTH CARE, INC. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE SUCH RIGHTS AND POWERS AS ARE PROVIDED FOR IN THE ARTICLES OF INCORPORATION, THE BYLAWS OF THE ORGANIZATION AND THE LAWS OF THE STATE OF MONTANA, INCLUDING BUT NOT LIMITED TO, THE EXCLUSIVE POWER: (A) TO REMOVE ANY TRUSTEE FROM ANY OFFICE AT ANY TIME, WITH OR WITHOUT CAUSE; (B) TO PROPOSE AND APPROVE (I) A PLAN OF DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION OR (II) A PLAN OF MERGER OR CONSOLIDATION OF THE ORGANIZATION WITH ANOTHER CORPORATION; (C) TO PROPOSE AND APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION AND OR THE BYLAWS;(D) TO ADOPT ANY ANNUAL OR LONG-TERM CAPITAL OR OPERATIONAL BUDGET OR ANY CHANGES THEREIN EXCEEDING $75,000;(E) TO AUTHORIZE THE ORGANIZATION TO ENTER INTO ANY CONTRACT OR ENGAGE IN ANY TRANSACTION WHICH IS NOT PROVIDED FOR IN AN ANNUAL OR LONG-TERM CAPITAL OR OPERATIONAL BUDGET APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION WHERE THE AMOUNT INVOLVED EXCEEDS $50,000;(F) TO ADOPT SUBSTANTIVE CHANGES TO EXISTING LONG-TERM OR MASTER INSTITUTIONAL PLANS OF THE ORGANIZATION; (G) TO AUTHORIZE THE ORGANIZATION TO ENGAGE IN, OR ENTER INTO, ANY TRANSACTION PROVIDING FOR THE SALE, MORTGAGE OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION; (H) TO ORGANIZE OR ACQUIRE, OR AUTHORIZE THE ORGANIZATION OR ACQUISITION OF, ANY SUBSIDIARY OR AFFILIATE OF THE ORGANIZATION; (I) TO AUTHORIZE THE ORGANIZATION TO ENTER INTO ANY SHARED SERVICE AGREEMENT; (J) TO APPROVE LONG-TERM BORROWING OF MONEY BY THE ORGANIZATION OR AUTHORIZE THE ORGANIZATION TO INCUR INDEBTEDNESS INVOLVING A MORTGAGE OR LIEN ON ASSETS; OR (K) TO APPROVE THE TRUSTEES OR THE PRESIDENT OF THE ORGANIZATION FROM A SLATE PREPARED BY THE NOMINATING COMMITTEE OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEE HAS THE AUTHORITY TO ACT ON BEHALF OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF THE FORM 990 WILL BE REVIEWED BY THE VP OF FINANCE, THEN SUBMITTED VIA E-MAIL TO THE BOARD OF DIRECTORS TO VIEW BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL TRUSTEES, DIRECTORS, OFFICERS, AND KEY EMPLOYEES. THE BOARD IDENTIFIES POTENTIAL CONFLICTS FROM ANNUAL DISCLOSURES. DISCLOSURES ARE REVIEWED BY ADMINISTRATION AFTER ALL ARE GATHERED. A SECOND CONFLICT DISCLOSURE LETTER IS SENT OUT ANNUALLY TO ALL CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TO ENSURE ALL POTENTIAL CONFLICTS ARE IDENTIFIED. THE RESULTS OF THIS DISCLOSURE FORM ARE REVIEWED BY THE VP OF FINANCE. THE BOARD DISCUSSES THE POTENTIAL CONFLICTS AND DETERMINES IF VOTING ON RELATED ITEMS WOULD BE A CONFLICT OF INTEREST. IF A CONFLICT IS DETERMINED TO EXIST, THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE CONFLICTED ITEM. FORM 990, PART VI, SECTION B, LINE 15A THE CEO/PRESIDENT IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY. THE EXECUTIVE COMMITTEE OF THE BOARD MEETS AND REVIEWS NORTHERN MONTANA HOSPITAL(NMH)/NORTHERN MONTANA HEALTH CARE, INC.(NMHC) FINANCIAL RESULTS, THE CEO'S CURRENT YEAR PRIORITIES, DISCUSS EVALUATION TOOLS TO BE USED FOR CEO EVALUATION, HOW COMPARATIVE SALARIES WILL BE OBTAINED AND DISCUSS THE HISTORY OF COMPENSATION TO THE CEO. AT A SECOND EXECUTIVE COMMITTEE MEETING THEY REVIEW NON-FINANCIAL ACTIVITY OF NMH/NMHC AND THE RESULTS OF THE CEO EVALUATIONS COMPLETED BY THE BOARD MEMBERS. THEN THEY REVIEW AND DISCUSS A COMPENSATION COMPARATIVE SUMMARY OF MONTANA CEO'S COMPENSATION AND A GUIDESTAR CEO COMPENSATION CHECKPOINT THAT IS PREPARED SPECIFICALLY FOR NMH. THEY AGREE UPON A LIST OF THE COMING YEAR'S PRIORITIES FOR THE CEO AND PROPOSED COMPENSATION, WITH THE COMPENSATION SET BY BOARD VOTE. THIS ANNUAL PROCESS WAS LAST PERFORMED DURING THE TAX YEAR ENDED JUNE 30, 2011. FORM 990, PART VI, SECTION C, LINE 19 FORM 990, PART VI, SECTION C, LINE 19: THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER THE IRS INSTRUCTIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 503,536. MINIMUM PENSION LIABILITY ADJUSTMENT: 2,439,058. EQUITY TRANSFER TO RELATED ORGANIZATION: -500,000. ROUNDING 2. TOTAL TO FORM 990, PART XI, LINE 5: 2,442,596. FORM 990, PART XII, LINE 2C: THE CONTROLLING ORGANIZATION, NORTHERN MONTANA HEALTH CARE, INC.'S BOARD HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT AUDITOR. ORGANIZATIONS: FORM 990, PART VII, SECTION A, PERCENTAGE OF TIME SPENT BETWEEN RELATED NO INDIVIDUALS ARE COMPENSATED FOR THEIR BOARD SERVICE TO EITHER ORGANIZATION, ONLY FOR THEIR SERVICE AS EMPLOYEES OF THE HOSPITAL. THE FOLLOWING INDIVIDUALS SPEND 2% OF THEIR TIME ON NMHC BUSINESS AND 98% OF THEIR TIME ON NMH BUSINESS: -VICE PRESIDENT OF NMHC ALSO SERVES AS THE VP OF NMH. -THE VICE CHAIR OF NMHC ALSO SERVES AS THE VICE CHAIR AND AN EMPLOYED PHYSICIAN OF NMH. -THREE TRUSTEES OF NMHC ALSO SERVE AS TRUSTEES AND EMPLOYED PHYSICIANS (INCLUDING THE MEDICAL DIRECTOR AND CHIEF OF STAFF) OF NMH. THE FOLLOWING INDIVIDUALS SPEND 2% OF THEIR TIME ON NMHC BUSINESS AND 2% OF THEIR TIME ON NMHCF BUSINESS AND 96% OF THEIR TIME ON NMH BUSINESS: -CEO/PRESIDENT OF NMHC ALSO SERVES AS THE CEO/PRESIDENT OF NMH AND NMHCF. -VP OF FINANCE OF NMHC ALSO SERVES AS THE VP OF FINANCE OF NMH AND NMHCF. THE REMAINING MEMBERS OF THE BOARD OF TRUSTEES SPEND 50% OF THEIR TIME ON NMHC BUSINESS AND 50% OF THEIR TIME ON NMH BUSINESS. NONE OF THEM ARE EMPLOYED BY EITHER ORGANIZATION. NORTH CARE CORPORATION 30 13TH STREET HAVRE MT 59501 810447638 SUPPORTING ORGANIZATION MT 501(C)(3) LINE 3 NORTHERN MONTANA HEALTH CARE INC 0 NORTHERN MONTANA HEALTH CARE INC PO BOX 1231 HAVRE MT 59501 810428854 SUPPORTING ORGANIZATION MT 501(C)(3) LINE 11B, II N/A 0 NORTHERN MONTANA HEALTH CARE FOUNDATION INC PO BOX 1231 HAVRE MT 59501 363464641 FUNDRAISING MT 501(C)(3) LINE 7 NORTHERN MONTANA HEALTH CARE INC 0 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 1 1 0