2011-05-16T18:29:17-05:00 2010-06-30 CHMS PC 741 3rd Ave S Glasgow MT 59230 990 2009-07-01 810243720 SHERIDAN MEMORIAL HOSPITAL ASSN SHER 4067651420 440 W LAUREL AVENUE PLENTYWOOD MT 59254 SANDRA CHRISTENSEN 4067651420 2011-05-16 1 Richard A Wiens CPA 4062289391 2009 2016-02-24 21:20:13Z SANDRA CHRISTENSEN 440 W LAUREL AVENUE PLENTYWOOD MT 59254 10095909 0 X www.sheridanmemorial .net X 1920 MT provide quality care to improve the health and well being of the people and community we serve. 7 7 248 75 0 0 187527 200063 9119644 9733481 33738 20442 232861 141923 9573770 10095909 0 0 5544541 6294786 0 56466 3843366 4103493 9387907 10398279 185863 -302370 8333660 8249011 758421 976142 7575239 7272869 PROVIDING QUALITY CARE TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE AND COMMUNITY WE SERVE. We are committed to the future healthcare needs of our community. We endeavor to be a leader and innovator in providing reliable, compassionate, comprehensive, high quality, cost effective healthcare services. 0 0 8340834 9733481 A COMMUNITY HOSPITAL AND NURSING HOME THAT BENEFITS THE PEOPLE IN SURROUNDING AREA. 8340834 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 5 0 248 1 0 0 0 0 0 0 0 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SANDRA CHRISTENSEN CFO 4067651420 440 W LAUREL AVENUE PLENTYWOOD MT 59254 DANETTE RASMUSSEN 1.00 X X 0 0 0 LINDA NELSON 1.00 X X 0 0 0 KATHY HAGAN 1.00 X X 0 0 0 DAVID FULKERSON 1.00 X 0 0 0 BILL MCCOY 1.00 X 0 0 0 DANNY MOORE 1.00 X 0 0 0 BUTCH MICHELS 1.00 X 0 0 0 SANDRA CHRISTENSEN 40.00 X 87317 0 6716 87317 0 6716 0 0 0 0 MARK S HEGYES MD 2323 32 ND STREET W BILLINGS MT 59102 PHYSICIAN SERVICES 203666 1 102473 97590 200063 PATIENT REVENUE 621990 9733481 9733481 9733481 20442 20442 13253 13253 13253 13253 HOSPITAL DISTRICT SUBS 621990 128670 128670 128670 10095909 9895846 0 0 95239 95239 5140783 4168813 951615 20355 71194 56227 14255 712 502554 397017 100511 5026 485016 383163 97003 4850 878414 691003 187411 13463 282 9162 4019 1139808 935522 184018 20268 830691 570689 258766 1236 40858 35689 5169 38419 37295 1124 687876 633843 54033 PROVISION FOR BAD DEBTS 372386 372386 EMPLOYEE RECRUITMENT 58569 33962 24607 EDUCATION 43009 24943 18066 10398279 8340834 2000979 56466 1319840 1021015 954649 632454 1181663 1267332 192211 401454 113951 139426 51056 34272 14349010 9764598 4353930 4584412 166360 168646 8333660 8249011 596657 844892 161764 131250 758421 976142 X 7575239 7272869 7575239 7272869 8333660 8249011 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 79341 79341 8428048 5652620 2775428 5604243 3990025 1614218 237378 121953 115425 4584412 10095909 10398279 -302370 -302370 1 1 1 X 1 X 1 1 1 0 1 1 188112 0 188112 0.01880 992734 906145 86589 0.00860 0 0 1180846 906145 274701 0.02740 0 0 0 0 0 0 0 0 0 0 1180846 906145 274701 0.02740 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 338827 18762 1958310 1781828 176482 X 1 1 SHERIDAN MEMORIAL HOSPITAL ASSN

440 W LAUREL AVE PLENTYWOOD MT 59254

X X X Part I, Line 3c: INDIVIDUALS APPLYING FOR CHARITY CARE MUST PROVIDE PAY STUBS, THIER MOST RECENT TAX RETURN, FORMS APPROVING OR DENYING ELIGIBILITY FOR MEDICAID AND OR STATE OR COUNTY FUNDED MEDICAL ASSISTANCE, FORMS APPROVING OR DENYING UNEMPLOYEMENT COMPENSATION AND CURRENT BANK STATEMENTS. THE ITEMS LISTED ABOVE WILL BE USED TO DETERMINE FAMILY INCOME. FAMILY INCOME AND FAMILY SIZE ARE THEN USED TO DETERMINE WHAT THE POVERTY THRESHHOLD IS FOR THE APPLICANT AND TO DETERMINE IF FREE OR DISCOUNTED CARE WILL BE APPROVED. Part III, Line 4: ACCOUNTS RECEIVABLE ARE CARRIED NET OF AN ESTIMATE FOR UNCOLLECTIBLES AND ALLOWANCES. ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS ARE SET BASED ON HISTORICAL LOSS RATES APPLIED TO AGED ACCOUNTS RECEIVABLE. ACCOUNTS WHICH ARE NOT CONSIDERED COLLECTIBLE ARE WRITTEN OFF AGAINST THE ALLOWANCE ACCOUNT. BAD DEBTS ARE CLASSIFIED AS AN OPERATING EXPENSE. Part III, Line 8: THE COST TO CHARGE RATIO IS USED TO DETERMINE COMMUNITY BENEFIT. THIS IS DONE BY APPLYING THE RATIO TO THE TOTAL MEDICARE REVENUE. THE SHORTFALL OCCURRS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. Part III, Line 9b: A PATIENT ACCOUNTS REP MAINTAINS A CURRENT AGING REPORT MONTHLY. AN ACCOUNT IS CONSIDERED DELINQUENT IF IT IS NOT PAID WITHIN THIRTY DAYS OF THE MAILING OF THE FIRST STATEMENT. IF PAYMENT IS NOT RECEIVED IN THE FOLLOWING BILLING CYCLE, THE PATIENT IS IS ISSUED A "PAYMENT MISSED" STICKER,ENCOURAGING PATIENTS TO MAKE PAYMENT. ALL BILLS ARE CONSIDERED PAST DUE IF NOT PAID BY THE THIRD BILLING CYCLE. A FINAL NOTICE WILL BE ISSUED IF PAYMENT IS NOT RECEIVED BY THE FOURTH BILLING CYCLE. IF PAYMENT IS NOT MADE WITHIN 5 BUSINESS DAYS AFTER THE FOURTH BILLING CYCLE THE PATIENT'S ACCOUNT WILL BE SENT TO COLLECTION. Form 990, Part VI, Section B, line 11 THE BOARD REVIEWS FORM 990 AT A REGULARD BOARD MEETING. Form 990, Part VI, Section B, line 12c THE BOARD IS REQUIRED TO SIGN THE CONFLICT OF INTEREST POLICY ANNUALLY. Form 990, Part VI, Section B, line 15 THE BOARD REVIEWS AND DECIDES THE COMPENSATION FOR THE ORGANIZATION'S CEO. THE CEO DETERMINES THE COMPENSATION PACKAGES FOR KEY EMPLOYEES BASED ON A WAGE SCALE. Form 990, Part VI, Section C, line 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST AND FINANCIAL STATEMENTS, ARE AVAILABLE UPON REQUEST. SHERIDAN HEALTHCARE FOUNDATION 440 W LAUREL AVE PLENTYWOOD MT 59254 810496987 SUPPORT SHERIDAN MEMORIAL HOSPITAL ASSN MT 501(A) 170(b)(1)(A)(vi) 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 sheridan healthcare foundation C 102473