2011-08-15T13:23:46-05:00 2010-09-30 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2009-10-01 237169376 Pawhuska Hospital Inc PAWH 9182873232 1101 East 15th Street Pawhuska OK 740561920 Karen Arrowsmith 9182873232 2011-08-12 1 Carolyn Levings 4054783334 2011-08-12 2009 2016-02-24 21:20:13Z Karen Arrowsmith 1101 East 15th Street Pawhuska OK 740561920 3074308 0 X N/A X 1972 OK HEALTH CARE SERVICES 5 5 69 0 0 0 312752 143846 2856754 2920936 23349 9526 0 3192855 3074308 0 0 2178053 2290633 0 0 985570 962139 3163623 3252772 29232 -178464 2663698 2416007 412604 343377 2251094 2072630 To provide care for persons suffering from illnesses or disabilities which require in or out patient hospital care. To carry on education activities and scientific research related to the care of the sick and injured and to promote the general health of the community. 0 0 2787113 2920936 Pawhuska Hospital is a 15-bed critical access hospital that accepts patients regardless of ability to pay. Charity care for the year ended September 30, 2010 was $82,097. 2787113 1 1 0 0 0 0 0 0 0 1 1 0 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 0 0 0 0 1 5 0 1 69 1 0 0 0 0 0 0 0 5 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 1 0 OK X Karen Arrowsmith 9182873232 1101 East 15th Street PAWHUSKA OK 740561920 James Hager 1.00 X X 0 0 0 Bob Roberts 1.00 X 0 0 0 Toby Bighorse 1.00 X X 0 0 0 Francis Altaffer 1.00 X 0 0 0 Nancy Woodyard 1.00 X 0 0 0 Karen Arrowsmith 50.00 X 86287 0 0 Mary Dagenaies 30.00 X 119532 0 0 John Ham 42.00 X 132152 0 0 337971 0 0 2 0 0 0 0 143846 143846 Net Patient Revenue 900099 2913951 2913951 Dietary Revenue 900099 6288 6288 Miscellaneous Revenue 900099 697 697 2920936 9526 9526 3074308 2920936 0 9526 89781 89781 1713832 1517808 196024 274280 201375 72905 212740 179379 33361 295134 295134 85356 85356 1155 1155 326537 257005 69532 52640 52640 9561 6660 2901 4609 4609 122485 122485 64217 64217 Sales & Use Tax 445 445 3252772 2787113 465659 0 509302 1050231 334574 374747 9488 12428 76591 109865 8738 15080 2874703 2021047 932001 853656 148004 645000 0 2663698 2416007 267604 272832 145000 0 70545 412604 343377 X 2251094 2072630 2251094 2072630 2663698 2416007 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 34360 34360 939310 567060 372250 35979 28003 7976 1837930 1425984 411946 27124 27124 853656 Third Party Settlements 70545 70545 3074308 3252772 -178464 0 -178464 3069699 -4609 -4609 3074308 0 3074308 3248163 0 3248163 4609 4609 3252772 Part XII, Line 2d - Other Adjustments: Interest expense included in revenue for financial statements: -4609. Part XIII, Line 4b - Other Adjustments: Interest expense included in revenue for financial statements: 4609. 1 1 X 1 X 1 X 1 0 0 0 1 639 94634 94634 0.02900 1 434115 180117 253998 0.07800 35300 508 34792 0.01090 2 639 564049 180625 383424 0.11790 2 639 564049 180625 383424 0.11790 0 444946 355957 2367234 2343796 23438 X 1 0 Pawhuska Hospital Inc

1101 E 15th St Pawhuska OK 740561920

X X X X Part I, Line 3c: The Medical Center provides it's services without regard to a patient's ability to pay. The Medical Center provides a discount of at least 25% of billed charges to all uninsured patients. Uninsured patients also may qualify for an additional 10% prompt pay discount. In addition to these automatic discounts, patients can apply for financial assistance including free and discounted care. The determination of the patient's qualification for financial assistance is based on an objective determination of the patient's financial resources and ability to pay. In general, all uninsured patients with household incomes of less than 150% of the Federal poverty guidelines qualify for free care. Patients with household incomes less than 300% of Federal Poverty Guidelines qualify for sliding scale discounts that are in addition to the automatic discount provided to all uninsured patients.Part I, Line 7: Charity care, unreimbursed medicaid and unreimbursed costs - other means-tested gov't programs are calculated at cost using the cost to charge ratio derived from worksheet 2. Part III, Line 4: Bad debt was converted to cost using the cost-to-charge ratio derived from Worksheet 2.The estimated amount of bad debt attributed to charity care is 80%. This is based on history of the organization's patients. The majority of the population served would qualify for government assistance or meet the federal poverty guidelines therefore if patients would have applied for financial assistance, the majority of the bad debt would have been classified as charity care.Pawhuska Hospital, Inc. considers care for the poor to be an essential part of its mission of service to the community.Bad Debt is reported net of discounts and contractual allowances. A Payment on an account previously written off reduces bad debt expense in the current year.Financial Statement Note:The carrying amount of patient receivables is reduced by a valuationallowance that reflects management's estimate of amounts that will not becollected from patients and third-party payors. Management reviews patient 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: 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 VI, Line 2: In the past we have discussed the health care needs of the local community during board meetings, as well as in the bi-monthly meetings of the medical staff. Administration, as well as the members of the board and the medical staff, have each been able to identify issues/needs to be addressed by the hospital. In addition, when looking at the potential of adding new services, an integral part of that research revolves around how such services will meet and address the different needs of our community. We are planning on developing future programs that will allow us the opportunity to gather a larger community audience that can inform us as to the issues that are important to the community and to gather suggestions from those involved. Programs such as the use of focus groups will enable us to further educate ourselves as to the needs of our community, and to develop programs to further meet those needs. Part VI, Line 3: Pawhuska Hospital, Inc. provides a letter to patients upon admission that states our hospital provides assistance to those patients who have limited income to help pay for hospital expenses. The letter indicates that Charity Care applications are available to all patients and can be picked up at the time of service or at a later date. The Charity Care application gives an overview of our Charity Care policy and notes that Medicaid and other State programs are also available to patients that meet income requirements. Our staff is available to offer patients assistance in completing the application if needed. Part VI, Line 4: Pawhuska Hospital, Inc. primarily serves the citizens of the community of Pawhuska, Oklahoma and the surrounding area. Pawhuska serves as the county seat of Osage County, Oklahoma and is also the capital of the Osage Nation. The hospital is one of two facilities located in Osage County. Pawhuska is located in a rural area, with the city's population being 3,584 and the overall county population of 47,472 (2010 Census). The per capita income for the city was $13,916. About 13.7% of families and 17.5% of the population were below the poverty line, including 22.3% of those under age 18 and 14.9% of those age 65 or over. The hospital is located within federally-designated underserved areas for primary care health professionals, mental health professionals, dental care health professionals and is located in a medically underserved area/population. The entire county falls into two medically underserved areas: Osage Service Area and West Osage Service Area. Part VI, Line 5: Currently, Pawhuska Hospital, Inc. does not have a Community Building Activity in place but is working to develop one. Part VI, Line 6: The organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care. The hospital operates an emergency room that is available to all, regardless of ability to pay. Form 990, Part VI, Section B, line 11 The Form 990 is presented to the Administrator for review and then presented to the Board of Directors. The Form 990 is filed after review by the Board of Directors. Form 990, Part VI, Section B, line 12c All employees, board members, and contract employees are covered in our policies. The employee and contract employee determinations are made by Administration and any board determinations are made by the Governing Board. The employee will be asked to remedy the situation and the board member will be asked to leave after presenting their conflict and the remainder of the Governing Board will discuss and then vote. Copies of both policies can be provided. Form 990, Part VI, Section B, line 15b Pawhuska Hospital follows the pay guidelines per our mananaging company Jane Phillips Medical Center. Form 990, Part VI, Section C, line 19 Documents are available upon request.