2011-05-16T11:09:05-05:00 2010-06-30 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2009-07-01 710276839 Delta Memorial Hospital DELT 8703824303 811 Hwy 65 S Dumas AR 71639 Cris Bolin 8703824303 2011-05-13 1 Richard Ruvelson 9525483400 2011-05-13 2009 2016-02-24 21:20:13Z Cris Bolin 811 Hwy 65 S Dumas AR 71639 17390241 0 X www.deltamem.org X 1975 AR AT DELTA MEMORIAL HOSPITAL, WE ARE COMMITTED TO AID HEALING AND PROMOTE WELLNESS FOR SOUTHEAST ARKANSAS IN A COURTEOUS, COST-EFFECTIVE AND CARING MANNER. 7 4 199 25 0 0 111998 84860 13093376 17181214 17036 2924 61510 90311 13283920 17359309 0 0 5717327 7528112 0 0 9019891 9092265 14737218 16620377 -1453298 738932 15373386 15350822 6794979 6033483 8578407 9317339 AT DELTA MEMORIAL HOSPITAL, WE ARE COMMITTED TO AID HEALING AND PROMOTE WELLNESS FOR SOUTHEAST ARKANSAS IN A COURTEOUS, COST-EFFECTIVE AND CARING MANNER. 0 0 14863903 17181214 Delta Memorial Hospital Provides Medical Health Care Services to Patients regardless of race, creed, sex, national origin, handicap, or ability to pay. Delta Memorial Hospital had 3568 inpatient days during the fiscal year. The organization had 10,506 clinic visits and Home Health served 15,080 individuals. 14863903 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 26 0 199 1 0 0 0 0 0 0 0 0 0 7 4 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Cris Bolin 8703824303 811 Hwy 65 S Dumas AR 71639 James Berry 1.00 X 0 0 0 Timothy Jones 1.00 X 0 0 0 Glenn Crow 1.00 X 0 0 0 Benny Estes 1.00 X X 0 0 0 Don Livingston 1.00 X X 0 0 0 Cobra Shanley DO 1.00 X 61000 0 0 Bruce Gasaway 1.00 X 0 0 0 Dr Thomas Lewellen 1.00 X 248500 0 0 Cris Bolin 40.00 X 92626 0 10324 Dr F David Chambers 40.00 X 808192 0 14390 Dr Peter Go 40.00 X 627821 0 8907 1838139 0 33621 3 0 1 1 Tree Frog Industries Inc 2840 Hwy 95 Alt South 7 Silver Springs NV 89429 ER Physician Services 971400 Ballard Ishee Corporation 125 Carlton Dr Dumas AR 71639 Professional Services 536700 Therex Inc Dept AT 952740 Atlanta GA 31192 Physical Therapy Services 532907 CPP Wound Care 3017 N Causeway Blvd Metairie LA 70002 Professional Services 231840 Quality Health Network 334 E Farrell Rd Lafayette LA 70508 Administrative Management 177594 6 7450 77410 84860 Patient Service Revenu 621990 16075289 16075289 Arkansas State Assessm 621990 1098871 1098871 Medical Records Revenu 900099 5254 5254 Clinic Rents 531120 1800 1800 17181214 25005 25005 4848 26929 -22081 -22081 -22081 3797 7450 4003 -206 -206 Meal and Vending Reven 900099 56468 56468 County Tax Millage 900099 34049 34049 90517 17359309 17181214 0 93235 112562 112562 6485142 5639873 845269 12882 11203 1679 490280 426377 63903 427246 365586 61660 43712 43712 40661 40661 2975096 2905718 69378 7627 7627 982435 891006 91429 599840 506943 92897 117442 96665 20777 277375 234418 42957 830232 701655 128577 227757 192485 35272 Bad Debt Expense 2411620 2411620 Patient Service Costs 430287 430287 Other Expense 148181 50067 98114 16620377 14863903 1756474 0 129586 211923 320802 273172 2836296 3560835 183733 183837 37353 55813 16351931 5327945 11824360 11023986 41256 41256 15373386 15350822 2605372 2306887 19451 2978397 3814839 476140 355317 272059 6794979 6033483 X -81269 1052031 8659676 8265308 8578407 9317339 15373386 15350822 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6105 6105 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: A portion of the dues paid to Arkansas Hospital Association is for lobbying expenses. 105910 105910 12407940 2800726 9607214 3644173 2527219 1116954 193908 193908 11023986 17359309 16620377 738932 0 738932 17757680 398371 398371 17359309 0 17359309 16624380 4003 4003 16620377 0 16620377 Part X: Description of Uncertain Tax Positions Under FIN 48: The organization recorded no assets or liabilities for uncertain tax positions or unrecognized tax benefits. Federal and state returns for 2007 and subsequent years remain subject to examination by major tax jurisdictions. Part XII, Line 2d - Other Adjustments: Fundraising Expense: 4003. Net assets released from restrictions - Used for operations: 394368. Part XIII, Line 2d - Other Adjustments: Fundraising Expense: 4003. 1 1 1 X 1 X 1 1 0 0 253735 253735 0.01790 3016942 2714349 302593 0.02130 3270677 2714349 556328 0.03920 191432 191432 0.01350 191432 191432 0.01350 3462109 2714349 747760 0.05270 0 2001053 1074582 5350747 5949540 -598793 X 1 1 Delta Memorial Hospital

811 Hwy 65 S Dumas AR 71639

X X X X Part I, Line 3c: Eligibility criteria for discounted care to low income individuals is as follows: 80% discount at 125% of FPG, 60% discount at 150% of FPG, 40% discount at 175% of FPG, 20% discount at 200% of FPG. Part I, Line 7: Part I, Line 7: The organization uses a cost to charge methodology as determined by worksheet 2 of the instructions. Part I, Line 7f: PART I, LINE 7, COLUMN F: AS ALLOWED, THE DENOMINATOR HAS BEEN REDUCED BY $2,411,620, THE AMOUNT OF BAD DEBT REPORTED IN PART IX, LINE 25 OF FORM 990. Part III, Line 4: The carrying amounts of accounts receivable are reduced by allowances that reflect management's best estimate of the amounts that will not be collected. Management provides for contractual adjustments under terms of third-party reimbursement agreements through a reduction of gross revenue and a credit to patient accounts receivable. In addition, management provides for probable uncollectible amounts, primarily from uninsured patients and amounts patients are personally responsible for, through a charge to operations and a credit to a valuation allowance based on its assessment of historical collection likelihood and the current status of individual accounts. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable. Part III, Line 8: The costing methodology used is cost to charge ratio as required by medicare. Part III, Line 9b: Patients that qualify for charity care are not put through collection process for the amount that qualifies for charity care. Part VI, Line 2: The organization assesses the health care needs of the community it serves through contracted research services. Part VI, Line 3: At admissions Charity Care is offered. Our social services coordinator is available to work with our Business Office Manager on other forms of assistance. Part VI, Line 4: We are a critical access hospital, and serve an underserved population in Dumas, Arkansas. Dumas, Arkansas is located in Desha county. Desha county has a median income of $27,555 as of 2008 with 29% of persons below the poverty level. Part VI, Line 5: Delta Memorial Hospital provides a variety of programs that promote health within the communities it serves. Delta provided physicals to Dumas Public Schools. Delta also had Family Night Outreach with 3 RNs and 3 LPNs went out into the community. Another program that promotes health in the community is the prescription assistance program. Part VI, Line 6: The board of directors is comprised of persons who reside in the primary service area. The organization promotes the health of the community by accomodating any financial concerns through the charity care program. Part VI, Line 7: N/A X X X 0 0 0 0 0 0 0 1 0 Dr Thomas Lewellen 0 0 0 0 248500 0 0 0 0 0 248500 0 0 0 Dr F David Chambers 574492 0 0 0 233700 0 0 0 14390 0 822582 0 0 0 Dr Peter Go 372921 0 0 0 254900 0 0 0 8907 0 636728 0 0 0 Part I, Line 7 Dr. David Chambers is paid a certain dollar amount for each patient seen in the clinic. Dr. Chambers also receives compensation through a contract for ER coverage. He received $135,400 for his ER Coverage services. He does not receive any other compensation from the organization. Supplemental Information Part III Dr. David Chambers, Dr. Peter Go, DR. Thomas L Lewellen and Dr. Cobra Shanley received wages from a third party vendor named tree frog LLc for emergency room services rendered to delta Memorial Hospital. Dr. Chambers and Dr. Go are also employees of Delta Memorial Hospital. Dr. Lewellen and Dr. Shanley are board members of Delta Memorial Hospital. Dr. Chambers received $98,300, Dr. Go received $106,900, Dr. Lewellen received $103,200 and Dr. Shanley received $45,600. Merchant & Farmers Bank Line of Credit X 750000 150000 0 0 1 Merchant & Farmers Bank clinic and equipment financing X 3000000 2828397 0 0 1 2978397 Bruce Gasaway Board Member of Organizaton and insurance broker of organization 71603 Insurance purchased through bruce gasaway an insurance broker. In the course of doing business, applications were sent to various insurance carriers and the best available policy was determined. 0 Form 990, Part VI, Section B, line 11 A copy of the Form 990 is provided to the board of directors for review and approval after submission. Form 990, Part VI, Section B, line 12c The organization requires disclosure of any conflicts of interest annually at the employee compliance meetings and at the annual board meeting. Form 990, Part VI, Section B, line 15 A comparison to market information available through various membership associations is used to determine compensation for the administrator and other top management. The comparative information is reviewed by the board of directors and compensation is approved by the board of directors. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy, and financial statements are available to the public upon request and at the monthly public board meetings. Form 990, Part XI, Line 2c The Board of Directors of the organization assumes responsibility for oversight of the audit and selection of an independent accountant. This process has not changed from prior year. Form 990, Part VII Compensation reported for Cobra Shanley and Thomas L Lewellen, PA is per contract to provide ER coverage and not in their capacity as directors of the organization.