2011-02-03T14:46:15-06:00 2010-06-30 SEIM JOHNSON SESTAK & QUIST LLP 8807 INDIAN HILLS DRIVE SUITE 300 OMAHA NE 681144123 990 2009-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 JACK W GREEN 4028874151 2011-01-27 1 Julie M Gerken 4023302660 2009 2016-02-24 21:20:13Z JACK W GREEN PO BOX 229 NELIGH NE 68756 12107758 0 X www.amhne.org X 1974 NE TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. 8 8 171 10 0 0 59464 120175 11339460 11826962 87992 98622 69054 61869 11555970 12107628 0 0 5985006 6206295 0 0 4741198 5124773 10726204 11331068 829766 776560 14582916 15120132 6104863 5830885 8478053 9289247 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 10222740 11826962 ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP, OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. 10222740 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 11 0 1 171 1 0 0 0 0 0 0 0 0 0 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 John Mlnarik 4.00 X X 0 0 0 James Blackburn 4.00 X X 0 0 0 James Meuret 2.00 X 0 0 0 David Sullivan 2.00 X 0 0 0 Joe Knight 4.00 X X 0 0 0 Philip Kluthe 2.00 X 0 0 0 Gordon Shrader 2.00 X 0 0 0 Christopher Twibell 2.00 X 0 0 0 Jack Green 40.00 X 136714 0 10145 Martha Nelson 36.00 X 87271 0 8082 Douglas Dilly 40.00 X 237152 0 16448 Troy Dawson 40.00 X 254139 0 17133 Roger Rudloff 40.00 X 272182 0 17137 987458 0 68945 4 0 1 0 Overland Rehab Services PO Box 298 Osmond NE 68765 Physical Therapy Services 246806 North Central Anesthesia Services PO Box 359 ONeill NE 68756 Anesthesia Services 234936 MedType Transcription Inc 404 North 28th St Norfolk NE 68701 Transcription Services 102622 3 120175 27457 120175 MEDICARE/MEDICAID PAYM 621400 7199436 7199436 OTHER PATIENT SERVICE 621400 4588914 4588914 LIFELINE 621990 26970 26970 LABORATORY 621990 6242 6242 AMBULANCE 621910 5400 5400 11826962 84277 84277 14475 130 14345 14345 14345 MISCELLANEOUS REVENUE 900099 34050 34050 CAFETERIA 900099 27819 27819 61869 12107628 11826962 0 160491 242212 242212 65060 65060 4723446 4253481 469965 154606 139345 15261 673058 589438 83620 347913 299746 48167 7981 7981 33771 33771 1416814 1311525 105289 37651 10868 26783 1568162 1520823 47339 217734 217734 38139 34527 3612 8996 7751 1245 213923 213923 857582 857582 169686 169686 BAD DEBT 498055 498055 DUES & SUBSCRIPTIONS 27562 27562 LICENSES 16658 2628 14030 MISCELLANEOUS EXPENSES 9053 9053 WELLNESS 3006 3006 11331068 10222740 1108328 0 1205338 1192756 3598905 3842605 62658 40302 1186692 1410822 425 14130 340817 351799 20468 23143 14459608 6730660 7667226 7728948 365336 395916 135051 119711 14582916 15120132 1399956 1534770 4170000 3990000 534907 306115 6104863 5830885 X 8477053 9258532 1000 30715 8478053 9289247 14582916 15120132 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1209 1209 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: PAID NEBRASKA HOPSITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES GOING TO LOBBYING ACTIVITIES OF $409 AND $800, RESPECTIVELY. 63764 63764 4592627 2119519 2473108 8110881 4207363 3903518 1692336 403778 1288558 7728948 ESTIMATED THIRD PARTY PAYORS 306115 306115 12107628 11331068 776560 34634 34634 811194 12142262 34634 34634 12107628 0 12107628 11331068 0 11331068 0 11331068 Part V, Line 4: Description of Intended Use of Endowment Funds: The $1,000 restriction is for an MRI unit. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital is a not-for-profit corporation as described in Section 501(c)(3) of the Code and has received a determination letter that it is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Internal Revenue Service has established standards to be met to maintain the Hospitals tax exempt status. In general, such standards require the Hospital to meet a community benefits standard and comply with various laws and regulations. The Hospital accounts for uncertainties in accounting for income tax assets and liabilities using guidance included in FASB ASC 740, Income Taxes. The Hospital recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. At June 30, 2010, the Hospital had no uncertain tax positions accrued. 1 1 1 X 0 1 1 0 1 1 18272 0 18272 0.00170 788222 601559 186663 0.01720 0 0 806494 601559 204935 0.01890 24807 9903 14904 0.00140 4000 0 4000 0.00040 637022 362857 274165 0.02530 0 0 1514 0 1514 0.00010 667343 372760 294583 0.02720 1473837 974319 499518 0.04610 1 348686 0 6153236 6215393 -62157 X 1 0 ANTELOPE MEMORIAL HOSPITAL

102 WEST 9TH STREET NELIGH NE 68756

X X X Part I, Line 3c: NOT APPLICABLE Part I, Line 6a: ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. Part I, Line 7: THE COSTING METHOD IS AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. Part I, Line 7g: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. Part I, Line 7f: THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $498,055. Part III, Line 4: Payment for services is expected within thirty days of initial billing. Accounts considered past due are sent to collection agencies when internal collection efforts have been unsuccessful. Any amounts deemed uncollectible are written off on a monthly basis. The Hospital does not charge interest on outstanding balances owed. The Hospital also maintains a charity care policy.PART III, SECTION A, LINE 2 WAS CALCULATED AS FOLLOWS:[(OPERATING EXPENSES - BAD DEBT) / (GROSS PATIENT SERVICE REVENUE + OTHER REVENUE)] X BAD DEBT.[(11,331,068 - 498,055) / 15,351,867 + 121,752] X 498,055 = 348,686.ALL INFORMATION IS FROM THE AUDITED FINANCIAL STATEMENTS. Part III, Line 8: PART III, SECTION B, LINES 5 & 6: THE INFORMATION IS DERIVED FROM THE MEDICARE COST REPORT D, E, H & M WORKSHEETS. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. Part III, Line 9b: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. Part V: ALL FACILITY INFORMATION IS ADEQUATELY ADDRESSED IN PART V. PART VI, LINE 8: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. Part VI, Line 2: CURRENTLY, ANTELOPE MEMORIAL HOSPITAL DOES NOT PERFORM ANY PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES. Part VI, Line 3: ANTELOPE MEMORIAL HOSPITAL includes ITS payment policy with all statements sent to patients. This policy explains our charity care program and gives instructions for the application process. Part VI, Line 4: The hospitals primary service area is Antelope County. Patients from the primary service area account for 84% of the Hospital's admissions. Currently there are two hospitals providing acute care services within Antelope County. Based on licensed beds, the Hospital is the largest acute care facility in Antelope County. The hospital's secondary service area encompasses the following five Nebraska counties: Boone, Holt, Knox, Madison, AND Pierce. In 2009, approximately 15% of the Hospitals patients were residents of the counties included in the secondary service area. Part VI, Line 5: CURRENTLY, THERE ARE NO COMMUNITY BUILDING ACTIVITIES CONDUCTED BY ANTELOPE MEMORIAL HOSPITAL. Part VI, Line 6: THERE ARE NO OTHER ACTIVITIES THAT FURTHER THE PROMOTION OF THE HEALTH OF THE COMMUNITY. Part VI, Line 7: ANTELOPE MEMORIAL HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. X X X 0 0 0 1 0 0 0 0 0 Douglas Dilly 237152 0 0 0 0 0 10814 0 5634 0 253600 0 0 0 Troy Dawson 238083 0 16056 0 0 0 11496 0 5637 0 271272 0 0 0 Roger Rudloff 267182 0 5000 0 0 0 11496 0 5641 0 289319 0 0 0 Part I, Line 5 PROFESSIONAL EMPLOYMENT AGREEMENTS ENTERED INTO BETWEEN THE HOSPITAL AND PHYSICIANS PROVIDES FOR AN ANNUAL INCENTIVE PAY IN WHICH THE RESPECTIVE PHYSICIAN RECEIVES A PERCENTAGE OF THE COLLECTIVE GROSS RECEIPTS FOR SERVICES PERSONALLY PERFORMED BY THAT PHYSICIAN AS LONG AS THE COLLECTIVE GROSS FEES EXCEED A SPECIFIED AMOUNT. HOSPITAL AUTHORITY NO 1 OF ANTELOPE CO NEBRASKA HOSPITAL REV BONDS 2004 900198231 03665RAR1 2004-07-01 4787394 HOSPITAL ADDITION 0 0 4860750 404835 84438 4371478 2005 0 0 1 1 0 0 1 0 1 0.02900 0.00000 0.02900 1 0 0 0 0 0 1 X TRANSFORMER 1 14108 FAIR MARKET VALUE X POLARIS RANGER 1 13349 FAIR MARKET VALUE 0 0 0 Form 990, Part VI, Section B, line 11 THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO REVIEWS FORM 990 AND PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. Form 990, Part VI, Section B, line 12c All Officers, Directors, committee members, and Key Employees shall review the conflict of interest policy and complete a conflict of interest questionnaire and certification upon initial affiliation with the Corporation and on an annual basis thereafter. Form 990, Part VI, Section B, line 15a Salary comparison data from the Nebraska Hospital Association is used to compare Administrator salary with that of other Nebraska critical access hospitals. The Chief Executive Officer and Chief Financial Officer salaries are determined using the Nebraska Hospital Association salary surveys and are then set by the Board of Directors. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. Form 990, Part VI, Section C, line 19 THE EXEMPT ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C OVERSIGHT OF AUDIT The full Board of Directors oversees SELECTION OF AN INDEPENDENT ACCOUNTANT AND the audit of the ANTELOPE MEMORIAL HOSPITAL's financial statements. SCHEDULE K, PART III, #3A MANAGEMENT OR SERVICE CONTRACTS During the applicable tax year, the organization was party to an agreement (the Agreement) with a group of anesthesiologists (the Physician Group). The Agreement permits members of the Physician Group to utilize certain portions of the surgery area of the organizations hospital facilities, which, in whole or in part, were financed with the proceeds of tax-exempt bonds. Although the terms of the Agreement may be subject to multiple interpretations, the Agreement did not fall clearly within the safe harbors provided under Revenue Procedure 97-13. Assuming that the Agreement is a management contract that gives rise to private business use of bond-financed facilities, the organization believes that the Agreement did not give rise to an impermissible level of private use, in that the Agreement (1) only relates to the use of approximately 750 square feet of bond-financed property out of a total of more than 25,800 square feet (resulting in use of less than three percent of the bond financed facility), (2) was only in effect for a portion of the time that the referenced bonds were outstanding, and (3) use by the Physician Group is not exclusive and is in common with the organizations employees and other users. In addition, it should be noted that the Agreement expired at the end of calendar 2010 and has since been replaced with a contract the terms of which are believed by the organization to fall within an applicable safe harbor of Revenue Procedure 97-13. SCHEDULE K, PART III, #7 MANAGEMENT PRACTICES AND PROCEDURES During the applicable tax year, the organization considered its transcript documentation (including the applicable tax regulatory agreement) as its management practices and procedures relating to post-issuance compliance.