2012-11-15T10:48:26-06:00 2011-12-31 450250958 EIDE BAILLY LLP PO BOX 1914 BISMARCK ND 58502 990 2011-01-01 450458242 SOUTHWEST HEALTHCARE SERVICES SOUT 7015233214 802 2ND ST NW BOWMAN ND 58623 BECKY HANSEN 7015233214 2012-11-15 1 LISA CHAFFEE CPA P00193453 7012551091 2012-11-15 2011 2016-02-24 21:20:13Z BECKY HANSEN 802 2ND ST NW BOWMAN ND 58623 11795213 0 X WWW.SWHEALTHCARE.NET X 2000 ND SOUTHWEST HEALTHCARE SERVICES IS ORGANIZED TO PROVIDE QUALITY HEALTH CARE SERVICES. 9 5 244 55 0 0 735108 938214 10957115 10803296 45685 37117 -601 4662 11737307 11783289 0 17076 0 0 6394451 6881252 0 0 0 4849974 5156956 11244425 12055284 492882 -271995 10166151 9976633 4440776 4578868 5725375 5397765 X GUIDED BY FAITH-BASED LEADERSHIP, WE ARE A FAMILY OF SPECIALISTS, EACH PERFORMING A UNIQUE SERVICE. WITH A SPIRIT OF COMPASSION, WE PROVIDE EXCELLENCE IN HEALTHCARE TO THOSE WE ARE PRIVILEGED TO SERVE. 0 0 10757433 17076 10803296 SOUTHWEST HEALTHCARE SERVICES (SOUTHWEST) CONSISTS OF A 23-BED ACUTE CARE HOSPITAL, 66-BED NURSING FACILITY, 14-UNIT APARTMENT COMPLEX, 12-UNIT ASSISTED LIVING FACILITY, VISITING NURSE SERVICE AGENCY, CLINIC, AND AMBULANCE SERVICE LOCATED IN BOWMAN, NORTH DAKOTA.SOUTHWEST HEALTHCARE SERVICES IS ORGANIZED TO PROVIDE QUALITY HEALTH CARE SERVICES FOR INDIVIDUALS IN THE SURROUNDING COMMUNITY. SOUTHWEST HEALTHCARE SERVICES OPERATES AN ACUTE CARE HOSPITAL, NURSING FACILITY, RURAL HEALTH CLINIC, AMBULANCE SERVICE, WELLNESS CENTER AND ELDERLY LIVING FACILITIES. SOUTHWEST OPERATES A FULL TIME EMERGENCY ROOM AND PROVIDES EMERGENCY CARE REGARDLESS OF ABILITY TO PAY. SOUTHWEST ALSO PROVIDES CLINICAL SERVICES NEEDED TO OPERATE THE EMERGENCY CENTER AND PROVIDES ON-SITE EMERGENCY MEDICAL, RESCUE AND MEDICAL TRANSPORTATION SERVICES.SOUTHWEST HEALTHCARE SERVICES PROVIDES NON-EMERGENCY SERVICES TO THE COMMUNITY MAKING THESE SERVICES ACCESSIBLE TO THE COMMUNITY THROUGH PARTICIPATION IN GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID AND OUR OWN CHARITY CARE PROGRAM. SERVICES ARE PROVIDED TO ALL INDIVIDUALS REGARDLESS OF INDIVIDUAL STATUS. SOUTHWEST HEALTHCARE SERVICES CHARITY CARE PROGRAM PROVIDES DISCOUNTED AND FREE SERVICES TO PATIENTS THAT ARE UNABLE TO BE FULLY RESPONSIBLE FOR THE COST OF THE HEALTH CARE THEY RECEIVE. SOUTHWEST HEALTHCARE SERVICES IS COMMITTED TO RESPONDING TO THE INCREASING NUMBER OF PATIENTS WHO ARE UNDER-INSURED OR WITHOUT INSURANCE AND WHO NEED TO SEEK HEALTHCARE SERVICES AT OUR FACILITY. TO FULFILL ITS MISSION OF COMMUNITY SERVICE, SOUTHWEST PROVIDES CARE TO THESE PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE SOUTHWEST DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT AND RESIDENT SERVICE REVENUE. THE AMOUNT OF CHARGES FOREGONE BASED ON ESTABLISHED RATES WAS $69,192 FOR THE YEAR ENDED DECEMBER 31, 2011. SOUTHWEST HEALTHCARE SERVICES REACHES OUT TO PEOPLE AND COMMUNITIES THROUGHOUT SOUTHWESTERN NORTH DAKOTA, NORTHWESTERN SOUTH DAKOTA AND EASTERN MONTANA THROUGH SPECIFIC HEALTH EVENTS AND HEALTH EDUCATION, FOR EXAMPLE: FREE SPORTS PHYSICALS FOR STUDENTS, HEALTH FAIRS, AND SKIN CANCER SCREENINGS. 10757433 1 1 0 0 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 0 1 24 0 1 244 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X SASHA RUGGLES CFO 7015233214 802 2ND ST NW BOWMAN ND 58623 SANDI TIVIS 1.00 X X 0 0 0 STEVE WILD 1.00 X X 0 0 0 CONNIE KRINKE 1.00 X X 0 0 0 ROSIE HILTON 1.00 X X 0 0 0 SUE JUNTUNEN 1.00 X 0 0 0 LYNN PETERSON 1.00 X 0 0 0 DAN SWANSON 1.00 X 0 0 0 GALEN STRAND 1.00 X 0 0 0 DAVE LARSON 1.00 X 0 0 0 JACKIE LAMBOURN 1.00 X 0 0 0 DENNIS GOEBEL 40.00 X 116911 0 5317 BECKY HANSEN 40.00 X 93391 0 15660 DR THOMAS MATHESON 15.00 X 188914 0 16318 DR FORREST LANCHBURY 40.00 X 295520 0 16318 CHRISTINE PETERSON 43.00 X 114345 0 0 809081 0 53613 4 0 1 0 DAKOTA TRAVEL NURSE 502 WEST MAIN ST MANDAN ND 58554 CONTRACT STAFFING 653201 PRAIRIE TRAVELERS INC 130 3RD ST STE 2 GLASGOW MT 59230 CONTRACT STAFFING 188747 R & L CONTRACTING 205 5TH AVE BOWMAN ND 58623 ROOF REPAIR 144776 AVERA HEALTH ECARE SERVICE 3900 W AVERA DR SUITE 301 SIOUX FALLS SD 57108 SERVICE CONTRACT 133230 4 23306 373767 541141 938214 PATIENT SERVICE REVENU 622110 10749599 10749599 OTHER PROGRAM SERVICE 622110 38613 38613 MEAL REVENUE 622110 14153 14153 MEDICAL SERVICES 622110 931 931 10803296 31402 31402 4615 1100 0 0 4615 1100 5715 5715 16586 23306 11924 4662 4662 11783289 10803296 0 41779 17076 17076 241059 241059 94900 94900 5581699 5154838 426861 536258 443601 92657 427336 380169 47167 19753 19753 33688 33688 2103073 1926072 177001 42196 42196 195616 88442 107174 5197 5197 239991 239991 86350 62975 23375 426 426 168188 168188 943740 943740 69495 69495 MEDICAL SUPPLIES 590920 590920 DIETARY FOOD AND SUPPLE 225222 225222 BAD DEBTS 195704 195704 RECRUITMENT 167880 126074 41806 69517 24829 44688 12055284 10757433 1297851 0 340419 82103 48215 22885 1941213 2306490 155151 152712 6527 51799 15875125 10883759 4920112 4991366 2276439 1651027 170408 478075 547843 10166151 9976633 1215776 1507316 79113 3225000 2990000 2439 4440776 4578868 X 5178056 4892521 420207 378132 127112 127112 5725375 5397765 10166151 9976633 X -271995 -55615 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 13232 6220 8845 10607 1 115112 219 -219 115112 115112 5502 5502 115112 115112 10913 10913 115112 1.00000 1 0 75488 75488 8920715 6023682 2897033 6368612 4606864 1761748 510310 253213 257097 4991366 DEFERRED FINANCING COSTS 70765 OTHER ASSETS 26600 RECEIVABLE FROM SUNRISE FOUNDATION 348902 CASH SURRENDER VALUE OF LIFE INSURANCE 26576 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 75000 547843 11783289 12055284 -271995 -37240 -18375 -55615 -327610 11409317 -37240 -37240 11446557 336732 336732 11783289 12058363 11924 11924 12046439 8845 8845 12055284 PART IV, LINE 1B: SOUTHWEST HEALTHCARE SERVICES HAS AN AUXILIARY THAT OPERATES UNDER THE SAME EIN AS SOUTHWEST HEALTHCARE SERVICES. PART IV, LINE 2B: SOUTHWEST ACTS AS CUSTODIAN FOR THE FUNDS OF THE RESIDENTS. THESE FUNDS ARE INCLUDED IN CASH AND ACCOUNTS PAYABLE IN THE FINANCIAL STATEMENTS. RESIDENT TRUST FUNDS TOTALED $2,439 AT DECEMBER 31, 2011. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENTS HELD AND ADMINISTERED BY SOUTHWEST HEALTHCARE SERVICES: THE EARNINGS FROM THE $115,112 ARE FOR HOSPITAL OPERATIONS, AS NECESSARY. THE PRINCIPAL OF $115,112 IS PERMANENTLY RESTRICTED. ENDOWMENTS HELD AND ADMINISTERED BY UNRELATED ORGANIZATIONS: THE PRINCIPAL AMOUNTS OF THESE ENDOWMENTS ARE NOT REFLECTED IN THE ACCOMPANYING FINANCIAL STATEMENTS BECAUSE THE FUNDS ARE NOT CONTROLLED BY SOUTHWEST AND ARE TO REMAIN INTACT. THE INTEREST EARNED IS TO BE USED BY SOUTHWEST FOR CAPITAL IMPROVEMENTS AND OPERATIONS. THE VALUE OF THESE FUNDS AT THE END OF THE YEAR WAS $745,168. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: SOUTHWEST 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. SOUTHWEST 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. IN ADDITION, SOUTHWEST IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. SOUTHWEST HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. PART XI, LINE 8 - OTHER ADJUSTMENTS: UNRESTRICTED NET ASSETS RELEASED FROM RESTRICTION 15,000. TEMPORARILY RESTRICTED NET ASSETS RELEASED FROM RESTRICTIONS -36,000. AUXILIARY NET LOSS 2,625. TOTAL TO SCHEDULE D, PART XI, LINE 8: -18,375. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY REVENUE 6,220. FUNDRAISING EXPENSES REPORTED IN REVENUE ON FORM 990 -11,924. CONTRIBUTION REPORTED IN FUND BALANCE ON FINANCIAL STATEMENTS 342,436. PART XIII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES REPORTED IN REVENUE ON FORM 990 11,924. PART XIII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 8,845. CELEBRITY WAITER 39892 23306 16586 350 6258 700 4616 39892 23306 16586 350 6258 700 4616 11924 4662 1 1 X 1 X 1 X 175.000000000000 1 1 1 0 0 64000 64000 0.00540 64000 64000 0.00540 2019936 1182043 837893 0.07070 2019936 1182043 837893 0.07070 2083936 1182043 901893 0.07610 0 195704 39141 2385542 2433008 -47466 X 1 1 1 1 SOUTHWEST HEALTHCARE SERVICES

14 6TH AVE SW BOWMAN ND 58623

X X X X X RURAL HEALTH CLINIC SOUTHWEST HEALTHCARE SERVICES 1 1 1 100.000000000000 1 175.000000000000 1 X X X 1 1 X X 1 0 1 X 1 1 3 SOUTHWEST HEALTHCARE SERVICES

802 2ND ST NW BOWMAN ND 58623

INDEPENDENT LIVING AND LTC BOWMAN AMBULANCE SERVICES

606 1ST ST SW BOWMAN ND 58623

AMBULANCE SERVICES SUNRISE VILLAGE

203 11TH AV NW BOWMAN ND 58623

ASSISTED LIVING AND HOME CARE PART I, LINE 7: THE ESTIMATED COST OF FINANCIAL ASSISTANCE REPORTED IN PART I, LINE 7, ROW A WAS CALCULATED BY MULTIPLYING THE RATIO OF COST TO GROSS CHARGES FOR SOUTHWEST BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CHARITY CARE TO ITS PATIENTS. THE AMOUNTS REPORTED IN PART I, LINE 7, ROW G WAS DETERMINED BASED ON THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR WAS $195,704. PART II: MANY OF THE SOUTHWEST HEALTHCARE SERVICES STAFF ARE TRAINED IN THE INCIDENT COMMAND SYSTEM FOR EMERGENCY PREPAREDNESS. WE PARTICIPATE IN LOCAL AND REGIONAL EMERGENCY DRILLS WITH LOCAL AUTHORITIES TO ASSIST US IN BEING PREPARED FOR MAJOR EMERGENCIES THAT COULD OCCUR IN OUR COMMUNITY. OUR EMS SERVICE STAFF PROVIDES CPR TRAINING (FOR A NOMINAL FEE) TO THOSE IN OUR COMMUNITY WHO ARE INTERESTED. THE HEALTH FAIRS/SCREENINGS THAT WE PROVIDE PERIODICALLY ARE A MEANS TO PROMOTE HEALTHY LIVING AND PREVENTIVE CARE TO OUR COMMUNITY. SOUTHWEST HEALTHCARE SERVICES EXTENDS EMERGENCY CARE SERVICES TO ALL PATIENTS IN OUR SERVICE AREA. IN ADDITION TO THE ACTIVITIES LISTED ABOVE, THE STAFF OF SOUTHWEST HEALTHCARE SERVICES PROVIDE COMMUNITY SUPPORT IN THE FOLLOWING WAYS: EMS STAFF SUPPORT AT PUBLIC SPORTING EVENTS SUCH AS MOTOCROSS RACES, RODEOS, AND SCHOOL SPORT ACTIVITIES. SUPPORT IS ALSO PROVIDED TO THE HIGH SCHOOL IN THE FORM OF SPORTS MEDICINE FOR THEIR SPORTS ACTIVITIES. STAFF HAVE PARTICIPATED IN LOCAL CAREER FAIRS TO PROMOTE HEALTHCARE CAREERS. PART III, LINE 4: FINANCIAL STATEMENT BAD DEBT EXPENSE FOOTNOTE:THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S 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 AND RESIDENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION.PATIENTS ARE ASKED TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION FOR CHARITY. THEIR ELIGIBILITY IS DETERMINED BY MEETING THE FOLLOWING CRITERIA: INCOME, EXPENSES, AND THE FEDERAL POVERTY GUIDELINES. A PATIENT MAY QUALIFY BY THE USE OF A SLIDING SCALE APPROACH, MEDICAL INDIGENCE OR THE PATIENT MAY BE PRESUMPTIVELY ELIGIBLE.WHEN A PATIENT QUALIFIES FOR ASSISTANCE UTILIZING THE ABOVE CRITERIA AN ADJUSTMENT FORM IS COMPLETED BY THE PATIENT REP AND FORWARDED TO THE CFO FOR AN APPROVAL SIGNATURE.WE REVIEW THE ACCOUNTS ON AN INDIVIDUAL BASIS WHEN WE TURN THEM OVER TO BAD DEBT. BASED ON WHAT WE SEE WHEN WE REVIEW THEM WE ESTIMATE THAT 20% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER OUR CHARITY CARE POLICY. WE CONSIDER THAT IF THEY WOULD HAVE DONE THE PAPERWORK REQUIRED TO OBTAIN CHARITY CARE, THEY MAY HAVE QUALIFIED. SOUTHWEST HEALTHCARE SERVICES DOES NOT REFUSE SERVICE TO PATIENTS THAT GENERATE BAD DEBT, AND THIS IS EVIDENCE THAT THE CARE IS GIVEN FOR COMMUNITY BENEFIT MOTIVATIONS. PART III, LINE 8: IRS REV. RUL. 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. IN SOME COMMUNITIES, MEDICARE IS THE LARGEST PAYER, AND HOSPITALS MUST ACCEPT THESE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SUCH SERVICES. IF THE MEDICARE PARTICIPATION IS PREMISED ON THIS FACT, THEN PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT. ALSO, THE ELDERLY ARE OFTEN AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS LIKE SOUTHWEST HEALTHCARE SERVICES PROVIDING MEDICARE SERVICES, THE GOVERNMENT WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY.MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE 2011 MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: EMPLOYEES WHO ARE RESPONSIBLE FOR REGISTERING PATIENTS ARE ASKED TO CONSIDER/SCREEN PATIENTS WHO MAY APPEAR TO QUALIFY OR WHO HAVE ASKED ABOUT FINANCIAL ASSISTANCE. THE REGISTRATION CLERK IS TO GIVE THE PATIENT A BROCHURE EXPLAINING THE FINANCIAL ASSISTANCE PROGRAM WHICH CONTAINS INFORMATION ON HOW TO ACCESS THE PATIENT FINANCIAL SERVICES REPRESENTATIVE (PFS) TO OBTAIN ASSISTANCE.THE PFS REP IS ALSO RESPONSIBLE FOR SCREENING PATIENTS THROUGH THE COLLECTION PROCESS FOR FINANCIAL ASSISTANCE. SOUTHWEST HEALTHCARE SERVICES PART V, SECTION B, LINE 13G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION CAN BE FOUND AT THE ADMISSIONS DESK IN THE HOSPITAL AND CLINIC. IT IS ALSO GIVEN TO ALL SELF-PAY PATIENTS. THE FINANCIAL ASSISTANCE APPLICATION CAN ALSO BE FOUND ON OUR WEBSITE. SOUTHWEST HEALTHCARE SERVICES PART V, SECTION B, LINE 19D: THE FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS WERE CHARGED AT GROSS CHARGES AND THEN FINANCIAL ASSISTANCE DISCOUNTS WERE APPLIED. THE ORGANIZATION IS EVALUATING APPLICABLE RATES TO BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. SOUTHWEST HEALTHCARE SERVICES PART V, SECTION B, LINE 20: THE FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS WERE CHARGED AT GROSS CHARGES AND THEN FINANCIAL ASSISTANCE DISCOUNTS WERE APPLIED. THE ORGANIZATION IS EVALUATING APPLICABLE RATES TO BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. SOUTHWEST HEALTHCARE SERVICES PART V, SECTION B, LINE 21: THE FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS WERE CHARGED AT GROSS CHARGES AND THEN FINANCIAL ASSISTANCE DISCOUNTS WERE APPLIED. THE ORGANIZATION IS EVALUATING APPLICABLE RATES TO BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. PART VI, LINE 2: THE ORGANIZATION IS CURRENTLY IN PROCESS OF COMPLETING A COMMUNITY HEALTH NEEDS ASSESSMENT. THIS IS EXPECTED TO BE COMPLETED IN EARLY 2013. PART VI, LINE 3: A SUMMARY OF OUR FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION CAN BE FOUND AT THE ADMISSIONS DESK IN THE HOSPITAL AND CLINIC. IT IS ALSO GIVEN TO ALL SELF-PAY PATIENTS. FINANCIAL ASSISTANCE CONTACT INFORMATION IS INCLUDED IN PATIENT BILLS AND IS DISCUSSED WITH PATIENTS AS WELL AS THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS. PATIENTS ARE ASSISTED WITH QUALIFICATION FOR SUCH PROGRAMS WHERE APPLICABLE. PART VI, LINE 4: THE COMMUNITY IS LARGELY AGRICULTURAL BASED BUT IN RECENT YEARS THE OIL AND GAS INDUSTRY HAS GROWN EXTENSIVELY. WE ANTICIPATE THAT THIS WILL INCREASE AT AN EVEN GREATER PACE IN THE NEXT SEVERAL YEARS THUS INCREASING THE PATIENT BASE THAT OUR ORGANIZATION WILL SERVE. THE CITY WE RESIDE IN IS LOCATED AT AN INTERSECTION OF TWO MAIN HIGHWAYS IN THE STATE OF NORTH DAKOTA. SOUTHWEST HEALTHCARE SERVICES IS THE LARGEST EMPLOYER IN THE CITY AND SERVES AN AREA THAT EXTENDS APPROXIMATELY 45 MILES IN ALL DIRECTIONS, NORTH, SOUTH, EAST AND WEST. THERE IS ONE OTHER RURAL HEALTH CLNIC IN OUR CITY LIMITS THAT IS OPERATED BY ANOTHER HEALTHCARE FACILITY WHICH IS 40 MILES FROM OUR CITY.SOUTHWEST HEALTHCARE SERVICES SERVES OVER 5,500 PEOPLE IN RURAL COUNTIES OF BOWMAN AND SLOPE, NORTH DAKOTA AND HARDING COUNTY IN SOUTH DAKOTA. WE HAVE BEEN VERY FORTUNATE, IN OUR SERVICE AREA, TO HAVE AN UNEMPLOYMENT RATE AT 2.3% WITH A MEDIAN INCOME OF $31,906. IN 2011, 1.5% OF PATIENTS USED MEDICARE AND 16% WERE NONINSURED. SOUTHWEST HEALTHCARE SERVICES IS THE ONLY HOSPITAL IN OUR SERVICE AREA WITH NO MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: SOUTHWEST HEALTHCARE SERVICES EXTENDS MEDICAL PRIVILEGES TO ALL PROVIDERS IN THE COMMUNITY, AND HAS A COMMUNITY BOARD. ANY SURPLUS FUNDS ARE USED FOR INVESTMENTS IN BOTH CAPITAL ASSETS, AND MEDICAL EQUIPMENT WHICH IMPROVE SERVICES AVAILABLE AS WELL AS THE QUALITY OF CARE THAT WE GIVE TO THE PATIENTS IN OUR SERVICE AREA. 1 STUDENT LOAN REPAYMENT 1 2000 TUITION SUBSIDY 3 15076 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: SOUTHWEST HEALTHCARE SERVICES OFFERS LOAN REPAYMENT ASSISTANCE TO EMPLOYEES WHO QUALIFY UNDER THE REQUIREMENTS OF THEIR NURSING LOAN REPAYMENT POLICY. THE ORGANIZATION USES THE POLICY PROCEDURES IN MONITORING THE USE OF GRANT FUNDS IN A COMPLIANT MANOR. NURSING STAFF SUBMIT DOCUMENTATION RELATED TO THEIR STUDENT LOANS IN ORDER FOR US TO DETERMINE IF THEY QUALIFY FOR THE LOAN REPAYMENT ASSISTANCE PROVIDED BY SOUTHWEST HEALTHCARE SERVICES. IN REGARD TO THE TUITION SUBSIDY THAT IS PAYABLE TO THE UNIVERSITY OF SOUTH DAKOTA, WE PARTICIPATED IN A GROW YOUR OWN NURSING PROGRAM AND THREE OF OUR STAFF RECEIVED THEIR NURSING DEGRESS THROUGH THIS PROGRAM. WE PROVIDED THIS TUITION SUBSIDY WHICH IS BASED ON THE NUMBER OF CREDIT HOURS ENROLLED IN AS WELL AS THE TOTAL NUMBER OF PARTICIPANTS IN THE PROGRAM. X 0 1 X X X 0 0 0 0 0 0 0 1 0 DR THOMAS MATHESON 188914 0 0 0 0 0 0 0 16318 0 205232 0 0 0 DR FORREST LANCHBURY 295520 0 0 0 0 0 0 0 16318 0 311838 0 0 0 PART I, LINE 1A HOUSING ALLOWANCE FOR DENNIS GOEBEL. THE SOUTHWEST HEALTHCARE SERVICES BOARD OF DIRECTORS DETERMINED THIS THROUGH A CONTRACT WITH THE INTERIM CEO. PART I, LINE 7 SOME PHYSICIANS ARE ELIGIBLE FOR A PRODUCTION INCENTIVE IN ADDITION TO BASE PAY. CITY OF BOWMAN NORTH DAKOTA 456002040 10302TAL4 2006-08-03 3902372 ADVANCE REFUND SERIES 1999 REVENUE BONDS AND FINANCE A BUILDING PROJECT 0 0 0 915000 3902372 78100 1482072 2342200 2010 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 11: THE AMOUNT REPORTED ON PART II, LINE 11 IS THE AMOUNT OF BOND PROCEEDS USED TO REFUND THE PRIOR BONDS ISSUED IN 1999. R & L CONTRACTING LYNN PETERSON IS ON THE BOARD AND A > 35% OWNER OF R & L CONTRACTING 115958 ROOF REPLACEMENT 0 ROCHELLE THOMPSON ROCHELLE IS THE DAUGHTER OF BOARD MEMBER GALEN STRAND 35108 COMPENSATION 0 KATRINA HECK KATRINA IS THE DAUGHTER-IN-LAW OF BOARD MEMBER CONNIE KRINKE 20754 COMPENSATION 0 JENNIFER WILD JENNIFER IS THE WIFE OF BOARD MEMBER STEVE WILD 39038 COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WHICH HAVE THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED INITIALLY BY THE CEO, CFO, AND ACCOUNTANT. THE RETURN IS THEN EMAILED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM ANNUALLY. THE FORMS ARE REVIEWED INITIALLY BY THE CEO FOR POTENTIAL CONFLICTS. ANY ACTUAL CONFLICTS ARE REVIEWED BY THE BOARD OF DIRECTORS. A PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS. FORM 990, PART VI, SECTION B, LINE 15 A REVIEW OF CURRENT SALARY SURVEYS FOR CEOS PROVIDED BY STATE ASSOCIATIONS IS REVIEWED AND A PERFORMANCE EVALUATION IS COMPLETED BY THE BOARD OF DIRECTORS. A FAIR COMPENSATION IS SET WITHIN THE SALARY SURVEY RANGES SUPPLIED AND AS DETERMINED BY THE EVALUATION REVIEW BY THE BOARD OF DIRECTORS. FOR THE CFO, COMPENSATION IS BASED ON A PERFORMANCE EVALUATION AS WELL AS A REVIEW OF CURRENT MARKET RATES THROUGH SALARY SURVEYS FOR COMPARABLE SIZED FACILITIES. THE CEO COMPLETES THE PERFORMANCE EVALUATION WHICH IS REVIEWED BY HUMAN RESOURCES AND IF THERE IS A NEED FOR A MARKET RATE ADJUSTMENT, THIS IS REVIEWED AT THE BOARD LEVEL WITH DISCUSSION AND DATA AND THEN APPROVED AT THAT TIME. THESE PROCESSES TAKE PLACE ON AN ANNUAL BASIS AND ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -37,240. UNRESTRICTED NET ASSETS RELEASED FROM RESTRICTION 15,000. TEMPORARILY RESTRICTED NET ASSETS RELEASED FROM RESTRICTIONS -36,000. AUXILIARY NET LOSS 2,625. TOTAL TO FORM 990, PART XI, LINE 5: -55,615. SOUTHWEST HEALTHCARE AUXILIARY 802 2ND ST NW BOWMAN ND 58623 CHARITABLE EVENTS TO HELP RAISE FUNDS FOR THE SWHC FACILITY. ND 6220 10606 N/A