2011-11-14T16:40:03-06:00 2010-12-31 DELAP LLP 4500 SW KRUSE WAY NO 200 LAKE OSWEGO OR 97035 990 2010-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL 5037692175 2011-11-11 1 WESLEY B HANSEN 5036974118 2010 2016-02-24 21:20:13Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 30324391 0 X WWW.SANTIAMHOSPITAL.COM X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 282 75 0 0 32294 14415 28216385 29586844 -63120 55803 372686 246509 28558245 29903571 0 0 0 0 14422527 15232619 0 0 0 12277638 13177344 26700165 28409963 1858080 1493608 23749491 26790939 2970303 4519000 20779188 22271939 SANTIAM MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE TO PERSONS SUFFERING FROM ILLNESS, INJURIES, OR DISABILITIES AND TO PROMOTE THE GENERAL HEALTH AND WELFARE OF THE COMMUNITY THROUGH EDUCATION, SUPPORT, AND MEDICAL SERVICES. 0 0 23771220 29702244 ACUTE HOSPITAL CARE: PATIENT DAYS 2,938, NURSERY DAYS 201, SWING BED DAYS 82, AMBULANCE TRIPS 1,502, OUTPATIENT DAYS 34,071, REFERENCE LABORATORY 111,157. 23771220 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 59 0 0 282 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 1 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X TERRY FLETCHALL 5037692175 1401 N TENTH AVENUE STAYTON OR 97383 RON ETZEL 2.00 X 0 0 0 ELAINE HANSEN 2.00 X 0 0 0 VICTOR KINTZ 2.00 X 0 0 0 MARYANN MEREDITH 2.00 X 0 0 0 MIKE ODENTHAL 2.00 X 0 0 0 RANDY MICKEY 2.00 X 0 0 0 GEORGE LONG 2.00 X 0 0 0 LAWRENCE FISHER 2.00 X 0 0 0 FRANCIS HENDRICKS 2.00 X 0 0 0 TERRY FLETCHALL 60.00 X X 212414 0 49607 MAGGIE HUDSON 60.00 X 156770 0 28607 GENNY BALDWIN 60.00 X 148335 0 35929 LORI BORELLA 32.00 X 288531 0 7565 FREDRICK CARLOCK 32.00 X 258505 0 7953 ERIC VON BORSTEL 32.00 X 229628 0 7303 ERIC WISER 60.00 X 226016 0 7353 AMY WISER 60.00 X 226016 0 6750 1746215 0 151067 8 0 1 0 CHARLES H STRINGHAM MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 447137 ROBERT L JACQUES MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 283400 MATTHEW G FAHEY MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 180278 JEANNE L FITZPATRICK MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 161420 4 7305 7110 14415 ACUTE HOSPITAL CARE 900099 30815188 30815188 MEDICARE/MEDICAID PMTS 900099 18026987 18026987 CASH DISC., MED RECORD 900099 42467 42467 PROVISION FOR CHARITY 900099 -1061623 -1061623 CONTRACTUAL ALLOWANCES 900099 -18236175 -18236175 29586844 17943 17943 94800 71348 23452 23452 23452 387332 338642 10830 48690 -10830 37860 37860 CAFETERIA REVENUE 900099 131109 131109 AIG RETRO PREMIUM 900099 91948 91948 223057 29903571 29702244 0 186912 2169319 1228696 940623 9179564 8084588 1094976 287811 242133 45678 2811004 1565831 1245173 784921 570601 214320 49050 49050 85776 85776 1842038 1812031 30007 92027 92027 56577 42433 14144 63060 63060 157905 151589 6316 185 185 7991 7991 1168812 1046332 122480 278164 262730 15434 SUPPLIES 3983789 3885133 98656 BAD DEBTS 3444404 3444404 CLINIC EXPENSE 550060 550060 MISCELLANEOUS 425879 47257 378622 EQUIPMENT RENTAL & MAIN 408572 331149 77423 563055 498262 64793 28409963 23771220 4638743 0 240 240 5188490 5421294 4633856 4890466 25100 22558 1042009 1170123 449832 648421 23275827 10975966 11166070 12299861 415781 550485 518600 525910 309513 1261581 23749491 26790939 2970303 4519000 2970303 4519000 X 20779188 22271939 20779188 22271939 23749491 26790939 X 1493608 -857 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 232930 1091087 1324017 990349 9621789 4812593 5799545 616390 414860 201530 8567118 5748513 2818605 5925 2150239 2156164 12299861 29903571 28409963 1493608 -857 -857 1492751 29902714 -857 -857 29903571 0 29903571 28409963 0 28409963 0 28409963 1 1 1 X 1 X 1 1 1 0 1 1 1 1480 535483 535483 0.01880 104374 3068336 2737963 330373 0.01160 1 105854 3603819 2737963 865856 0.03040 586 46512 5673 40839 0.00140 18504 18504 0.00070 586 65016 5673 59343 0.00210 1 106440 3668835 2743636 925199 0.03250 2 14410 14410 0.00050 2 14410 14410 0.00050 1 1737357 1389886 3205338 3605912 -400574 X 1 1 1 1 SANTIAM MEMORIAL HOSPITAL

1401 N 10TH AVENUE STAYTON OR 973831311

X X X SANTIAM MEMORIAL HOSPITAL 1 0 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X 1 X 0 1 X 0 1 5 SUBLIMITY MEDICAL CLINIC

114 SE CHURCH ST SUBLIMITY OR 97325

PHYSICIAN CLINIC AUMSVILLE MEDICAL CLINIC

205 MAIN ST AUMSVILLE OR 97325

PHYSICIAN CLINIC CASCADE MEDICAL CLINIC

1375 N 10TH AVENUE STE B STAYTON OR 97383

PHYSICIAN CLINIC SANTIAM MEDICAL CLINIC

280 S FIRST AVENUE MILL CITY OR 97360

PHYSICIAN CLINIC SANTIAM WOMEN'S CLINIC

1373 N 10TH AVENUE STAYTON OR 97383

PHYSICIAN CLINIC PART III, LINE 4: THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 2: THE GROSS BAD DEBT CHARGES, $1,737,357, WERE APPLIED TO THE PATIENT CARE COST TO CHARGES RATIO ESTABLISHED IN WORKSHEET 2. BAD DEBTS ARE DETERMINED AFTER THE PATIENT RECEIVED 4 STATEMENTS AFTER DATE OF SERVICE OR DATE OF PAYMENT BY INSURANCE. AFTER THE 4TH STATEMENT, THE PATIENT RECEIVES A LETTER EXPLAINING THAT THEIR ACCOUNT WILL BE TURNED OVER TO A COLLECTION AGENCY IF PAYMENT IS NOT RECEIVED BY THE END OF THE MONTH.THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 3: THROUGH OBSERVATION OF CHARITY CARE COORDINATOR, 80% OF BAD DEBTS MAY HAVE QUALIFIED FOR CHARITY CARE BECAUSE OF 1) INCORRECT CONTRACT INFORMATION GIVEN TO HOSPITAL, 2) UNABLE OR UNWILLINGNESS TO FILL OUT AND COMPLETE CHARITY CARE FORMS AND SUPPORTING DOCUMENTATION AND 3) THE STIGMA ASSOCIATED WITH THE ACCEPTANCE OF CHARITY CARE. PART III, LINE 9B: FINANCIAL ASSISTANCE IS GRANTED ON A SLIDING SCALE. IF AMOUNT DEEMED TO BE PAYABLE BY THE PATIENT IS DELINQUENT, THE PATIENT IS SENT TO COLLECTION AGENCY FOR THE PORTION OUTSTANDING. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: ALL PATIENTS ARE CHARGED AT THE SAME GROSS CHARGES. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 21: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGES REGARDLESS OF INSURANCE STATUS. ALL PATIENTS ARE GIVEN A 10% DISCOUNT FOR PAYMENT OVER $ 500. X X X 0 0 0 0 0 0 0 0 0 TERRY FLETCHALL 162818 0 30896 0 18700 0 30335 0 19272 0 262021 0 0 0 MAGGIE HUDSON 128203 0 15448 0 13119 0 11135 0 17472 0 185377 0 0 0 GENNY BALDWIN 128947 0 15448 0 3940 0 18457 0 17472 0 184264 0 0 0 LORI BORELLA 288531 0 0 0 0 0 7350 0 215 0 296096 0 0 0 FREDRICK CARLOCK 258505 0 0 0 0 0 7350 0 603 0 266458 0 0 0 ERIC VON BORSTEL 229628 0 0 0 0 0 6858 0 445 0 236931 0 0 0 ERIC WISER 226016 0 0 0 0 0 6750 0 603 0 233369 0 0 0 AMY WISER 226016 0 0 0 0 0 6750 0 0 0 232766 0 0 0 FORM 990, PART VI, SECTION A, LINE 4 AMENDED ARTICLE OF INCORPORATION. PLEASE SEE ATTACHED DOCUMENT. FORM 990, PART VI, SECTION A, LINE 7A THE HOSPITAL HAS APPROXIMATELY 400 MEMBERS WHO VOTE ON SELECTING BROAD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS, KEY EMPLOYEES AND CHIEF OF STAFF IS REQUIRED TO SIGN AN ANNUAL CONFLICT OF INTEREST STATEMENT ATTESTING TO THEIR COMPLIANCE. FORM 990, PART VI, SECTION B, LINE 15 SMH USES A THIRD PARTY COMPENSATION AND BENEFIT SERVICE: OLNEY & ASSOCIATES. THE SURVEY PROVIDES DATA ON HOSPITAL KEY EMPLOYEE COMPENSATION AND BENEFITS BASED ON BED SIZE, GEOGRAPHIC REGION, ADMISSIONS AND GROSS REVENUE. THE BOARD OF DIRECTORS REVIEW COMPENSATION AND BENEFITS FOR ADMINISTRATOR (TERRY FLETCHALL), DIRECTOR OF OPERATIONS & FINANCE (MAGGIE HUDSON) AND DIRECTOR OF NURSING (GENNY BALDWIN). THE ADMINISTRATOR'S CONTRACT IS THROUGH THE HOSPITAL APPROVED BY THE BOARD AND DIRECTOR OF NURSING AND DIRECTOR OF OPERATIONS & FINANCE CONTRACTS ARE WITH THE HOSPITAL APPROVED BY THE ADMINISTRATOR. FORM 990, PART VI, SECTION C, LINE 19 SANTIAM MEMORIAL HOSPITAL MAKES COPIES OF ITS GOVERNING DOCUMENTS AND AUDITED FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ALSO AVAILABLE BY CONTACTING THE STATE OF OREGON DEPARTMENT OF JUSTICE. THE CONFLICT OF INTEREST POLICY IS NOT AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -857. FORM 990, PART XII LINE 2C: THE ORGANIZATION HAS NOT CHANGED THE OVERSIGHT AND SELECTION PROCESS DURING THE TAX YEAR. SANTIAM MEMORIAL HOSPITAL AUXILIARY 1401 N 10TH AVENUE STAYTON OR 97383 237399406 OPERATION OF GIFT SHOP AT THE HOSPITAL OR 501(C)(3) LINE 3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 SANTIAM MEMORIAL HOSPITAL AUXILIARY M 0