2026-05-12T08:10:42-05:00 2025-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 DIANE BRUGGER CEO 4028874151 2026-05-11 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2026-05-11 2024 2025-03-06 01:10:19Z DIANE BRUGGER PO BOX 229 NELIGH NE 68756 27901102 0 X WWW.AMHNE.ORG X 1974 NE TO OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA. 10 10 221 18 0 0 88214 137107 20731714 26227241 479762 580246 246212 53075 21545902 26997669 4076 1625 0 0 12214996 13079173 0 0 0 8463803 11621870 20682875 24702668 863027 2295001 27682171 30887917 2097183 3007928 25584988 27879989 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 20836056 1625 26227241 ANTELOPE MEMORIAL HOSPITAL IS A 16-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. 20836056 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 37 0 1 221 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 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 PRESIDENT 4.00 X X 0 0 0 JAMES BLACKBURN VICE PRESIDENT THRU 5/2025 4.00 X X 0 0 0 JAMES MEURET VICE PRESIDENT 4.00 X X 0 0 0 SAMANTHA STOLTZ SECRETARY/TREASURER 4.00 X X 0 0 0 JON SCHILLING MEMBER 2.00 X 0 0 0 GORDON SHRADER MEMBER 2.00 X 0 0 0 MAURY SOPER MEMBER 2.00 X 0 0 0 DAVID SULLIVAN MEMBER 2.00 X 0 0 0 DR RUSSELL VETICK MEMBER 2.00 X 0 0 0 TOM ZWINGMAN MEMBER 2.00 X 0 0 0 ROBERT JOHNSTON MEMBER 2.00 X 0 0 0 CHRISTOPHER TWIBELL MEMBER THRU 1/2025 2.00 X 0 0 0 DIANE BRUGGER ADMINISTRATOR/CEO 40.00 X 299847 0 30798 MARTHA NELSON CFO 32.00 X 215843 0 26183 ROGER RUDLOFF MD PHYSICIAN 40.00 X 458203 0 33025 TROY DAWSON MD PHYSICIAN 40.00 X 391545 0 41555 KELLI OSBORN MD PHYSICIAN 40.00 X 298824 0 41555 TANYA SHARP CCOO 40.00 X 172496 0 25913 JOSHUA THOENDEL MD PHYSICIAN 40.00 X 385935 0 41555 2222693 0 240584 15 0 1 0 PSYCHIATRIC MEDICAL SERVICES 8 CADILLAC DRIVE SUITE 230 BRENTWOOD TN 37027 PSYCHIATRIC SERVICES 521191 PINNACLE ANESTHESIA SERVICES 608 EAST 4TH STREET NELIGH NE 68756 NURSING SERVICES 422401 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 348616 APPLIED CONNECTIVE TECHNOLOGIES LLC PO BOX 446 2508 SALEBARN RD ALBION NE 68620 IT SERVICES 185702 EIDE BAILLY 18081 BURT STREET SUITE 200 OMAHA NE 68022 ACCOUNTING SERVICES 130797 5 23832 113275 137107 NET PATIENT SERVICE REVENUE 621400 23591761 23591761 RETAIL PHARMACY 456110 1535375 1535375 340B REVENUE 456110 1015465 1015465 AMBULANCE 621910 7272 7272 77368 77368 26227241 525650 525650 908029 50000 903433 0 4596 50000 54596 54596 CAFETERIA 900099 53075 53075 53075 26997669 26227241 0 633321 X 1625 1625 571800 571800 10196642 9010693 1185949 279960 222668 57292 1321743 1059958 261785 709028 616079 92949 34302 20975 13327 57732 57732 3545015 2736312 808703 171524 9741 161783 778660 671584 107076 858401 575135 283266 275039 264000 11039 65924 59232 6692 1519747 1452647 67100 410372 392258 18114 MEDICAL SUPPLIES 2325315 2325315 RETAIL PHARMACY COSTS 1340700 1340700 DUES & SUBSCRIPTIONS 114862 54583 60279 MISCELLANEOUS 106887 15090 91797 17390 7461 9929 24702668 20836056 3866612 0 623392 300976 11994332 14428608 5100 5100 1603262 1906195 0 56319 419499 719310 113569 192318 32040681 19938550 12749089 12102131 173928 1176960 27682171 30887917 1863741 2474716 233442 533212 2097183 3007928 X 25561688 27843173 23300 36816 25584988 27879989 27682171 30887917 2295001 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2413 2413 0 PART II-B, LINE 1: PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. 124229 124229 10034005 5760073 4273932 17564538 11886455 5678083 4317909 2292022 2025887 12102131 ESTIMATED 3RD PARTY PAYER SETTLEMENT 533212 533212 X PART X, LINE 2: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. 1 1 X 1 X 125.000000000000 0 1 1 0 1 1 46000 46000 0.00190 2026127 1631434 394693 0.01600 2072127 1631434 440693 0.01790 69063 8009 61054 0.00250 4663546 2007877 2655669 0.10750 1625 0 1625 0.00010 4734234 2015886 2718348 0.11010 6806361 3647320 3159041 0.12800 400 0 400 0.00000 11549 0 11549 0.00050 11949 11949 0.00050 1 763857 87844 8795458 8841883 -46425 X 1 1 1 1 ANTELOPE MEMORIAL HOSPITAL 102 WEST 9TH STREET NELIGH NE 68756 WWW.AMHNE.ORG 020001 X X X ANTELOPE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 24 1 1 1 1 X WWW.AMHNE.ORG X 1 24 1 WWW.AMHNE.ORG 0 1 X 125.000000000000 X X X 1 1 X X X 1 X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X X X X X X 1 X 0 X X X X 1 X 0 0 ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: ANTELOPE MEMORIAL HOSPITAL COLLABORATED/CONTRACTED WITH THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) IN 2024 TO REVIEW DATA AND IDENTIFY HEALTH NEEDS IN OUR COMMUNITIES. AS A PARTICIPANT, ANTELOPE MEMORIAL HOSPITAL SHARED NCDHD'S ONLINE SURVEY ON THEIR WEBSITE AND FACEBOOK PAGE TO GAIN THE PERSPECTIVE OF THE COMMUNITY REGARDING HEALTH, COMMUNITY HEALTH ISSUES, AND QUALITY OF LIFE. THE SURVEY WAS COMPLETED IN OCTOBER OF 2024. THE RESULTS OF THE CHNA SURVEY WERE PRESENTED BY TOMMY GEORGE AT A COMMUNITY PRIORITIZATION MEETING HOSTED BY NCDHD ON MARCH 25, 2025. PARTNERS INCLUDED REPRESENTATIVES FROM HEALTHCARE FACILITIES, SCHOOLS, ECONOMIC DEVELOPMENT, AND CLERGY. ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: CHERRY COUNTY HOSPITALCHI HEALTH PLAINVIEWNIOBRARA VALLEY HOSPITALOSMOND GENERAL HOSPITALAVERA CREIGHTON HOSPITALAVERA ST. ANTHONY'S HOSPITAL ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENTBROWN COUNTY SHERRIFF'S OFFICERROMRSASERACARE HOSPICE, HBCCC, WH HEALTH MINISTRIESO'NEILL CHAMBER OF COMMERCEFAMILY SERVICE LINCOLNUNL EXTENSIONBOYD COUNTY SCHOOLSDHHSHEARTLAND COUNSELING SERVICESCITY OF CREIGHTONMIDTOWN HEALTH CENTERRURAL REGIONAL ONE HOLT COUNTY ECONOMIC DEVELOPMENTBRIGHT HORIZONSCHI HEALTH (REGIONAL COMMUNITY BENEFIT TEAM)NORTHEAST COMMUNITY COLLEGEGREATER SANDHILLS FAMILY HEALTHCARESANTEE HEALTH CENTER ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS COMPLETED IN 2024 AND IDENTIFIED THE FOLLOWING NEEDS: - MENTAL HEALTH - SUBSTANCE ABUSE- SOCIOECONOMIC INSTABILITY- ACCESS TO SERVICES- CHRONIC CONDITIONS & DISEASE PREVENTIONANTELOPE MEMORIAL HOSPITAL WAS ABLE TO ADDRESS ALL OF THE NEEDS BY COMBINING THE PRIORITY AREAS OF "MENTAL HEALTH & SUBSTANCE ABUSE PREVENTION AND "CHRONIC DISEASE & DISEASE PREVENTION" INTO "LIFESTYLE CHANGES" AS MOST DISEASE AND HEALTH ISSUES ARE A DIRECT RESULT OF THE LIFESTYLE CHOICES PEOPLE MAKE, AND THEY MAKE THE BIGGEST IMPACT ON PHYSICAL AND MENTAL HEALTH. THEREFORE NEEDS TO BE ADDRESSED ARE AS FOLLOWS:- LIFESTYLE CHANGES - SOCIOECONOMIC STABILITY - ACCESS TO SERVICESTHERE WERE NO SIGNIFICANT NEEDS IDENTIFIED THAT ARE NOT CURRENTLY BEING ADDRESSED.ACTIONS TAKEN DURING THE YEAR TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN THE PREVIOUS CHNA INCLUDE THE FOLLOWING:- HEALTH SCREENS AT THE NELIGH COMMUNITY CENTER- DIABETES EDUCATION AT THE NELIGH COMMUNITY CENTER- EDUCATION ON SIGNS/SYMPTOMS OF STROKE VIA MEDIA- EDUCATION ON SMOKING CESSATION VIA MEDIA- EDUCATION ON SKIN CANCER VIA MEDIA- DISCOUNTED LAB SPECIALS FOR THE PUBLIC- HEALTH FAIR FOR ERPPD EMPLOYEES- AMH STAFF TRAINED IN "MEASURE ACCURATELY", MOST UP-TO-DATE STANDARDS FOR BLOOD PRESSURE MEASUREMENT- FREE MEDICARE ENROLLMENT FOR THE PUBLIC- EDUCATION ON CANCER SCREENING GIVEN AT THE ANTELOPE COUNTY AG & HOME EXPO - BASIC LIFE SUPPORT (BLS) TRAINING OFFERED FOR FREE TO AMH STAFF- FREE LIFE-SAVING CLASS OFFERED TO THE PUBLIC- PARTICIPATION IN ACDC COALITION MEETINGS- EDUCATION ON MENTAL HEALTH AT THE NELIGH AND ELGIN COMMUNITY CENTERS- BINGO/MENTAL HEALTH EDUCATIONAL SESSIONS AT THE NELIGH COMMUNITY CENTER- EDUCATION ON MENTAL HEALTH VIA MEDIA- ASSISTING WITH MEALS-ON-WHEELS WITH MENTAL HEALTH EDUCATION- PARTICIPATED IN MENTAL HEALTH AWARENESS MONTH VIA MEDIA AND COMMUNITY EVENTSACTIONS TAKEN DURING THE YEAR TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENT CHNA INCLUDE THE FOLLOWING:- BINGO/MENTAL HEALTH EDUCATIONAL SESSIONS AT NELIGH COMMUNITY CENTER- PARTICIPATION IN ACDC (ANTELOPE COUNTY DOES CARE) COALITION MEETINGS- MONTHLY HEALTH SCREENS AT THE NELIGH COMMUNITY CENTER 5 1 - AMH FAMILY PRACTICE 109 WEST 11TH STREET PO BOX 109 NELIGH NE 68756 FAMILY PRACTICE MEDICAL CLINIC 2 - AMH TILDEN CLINIC 200 S ANTELOPE STREET TILDEN NE 68781 FAMILY PRACTICE MEDICAL CLINIC 3 - AMH CLEARWATER CLINIC 308 NEVADA STREET CLEARWATER NE 68726 FAMILY PRACTICE MEDICAL CLINIC 4 - AMH ELGIN CLINIC 101 WEST CEDAR STREET ELGIN NE 68636 FAMILY PRACTICE MEDICAL CLINIC 5 - ORCHARD MEDICAL CLINIC 103 WASHINGTON STREET ORCHARD NE 68764 FAMILY PRACTICE MEDICAL CLINIC PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE HOSPITAL ALSO USES ASSET LEVEL, INSURANCE STATUS AND UNDERINSURANCE STATUS TO DETERMINE ELIGIBILITY FOR FREE CARE. DISCOUNTED CARE IS NOT OFFERED, AS FINANCIAL ASSISTANCE IS BASED UPON AN ALL OR NOTHING POLICY. IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THEY WILL RECEIVE A 100% DISCOUNT. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS CALCULATED USING THE RATIO OF PATIENT COST TO CHARGES ON WORKSHEET 2. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDE THREE PHYSICIAN CLINICS IN NEIGHBORING COMMUNITIES, AS WELL AS PHYSICAL THERAPY SERVICES, PATIENT TRANSPORT AND CARDIAC REHAB. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES DURING THE YEAR INCLUDED THE FOLLOWING:- MEMBERSHIP DUES AND ATTENDANCE AT MONTHLY CHAMBER OF COMMERCE MEETINGS TO PROMOTE LOCAL BUSINESS AND WORKING FOR THE BETTERMENT OF THE COMMUNITY AS A WHOLE.- DEVELOPING THE WORKFORCE BY PROVIDING SCHOLARSHIPS TO INCREASE MEDICAL EDUCATION IN THE COMMUNITY, AS WELL AS OTHER PAYMENTS FOR ENSURING THE CONTINUOUS RECRUITMENT OF PHYSICIANS AND OTHER HEALTH PROFESSIONALS TO THE AREA. PART III, LINE 2: THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 11.5% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 13 AND 14 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.HOSPITAL SERVICES RENDERED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATIONS PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED THE HOSPITAL WOULD HAVE HAD A GREATER LOSS FROM MEDICARE SERVICES OF $50,102.MEDICARE FEE SCHEDULE REVENUE $108,476MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS $158,578NET (SHORTAGE) $(50,102) PART III, LINE 9B: IF A PERSON APPLIES FOR FINANCIAL ASSISTANCE IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE POLICY ALL COLLECTION EFFORTS WILL STOP UNTIL THE DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS MADE. IF THE PERSON QUALIFIES FOR FINANCIAL ASSISTANCE, THE HOSPITAL WILL TAKE STEPS TO REVERSE COLLECTIONS ACTION, REPORTS, AND OTHER ACTIONS THAT HAVE BEEN TAKEN TO OBTAIN PAYMENT. PART VI, LINE 2: ANTELOPE MEMORIAL HOSPITAL PERFORMED THE FOLLOWING PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES: - COMMUNITY FOCUS GROUP MEETINGS - CONFERENCE CALLS WITH DHHS PERSONNEL FOR INPUT, GUIDANCE, AND FEEDBACK - STRATEGIC PLANNING SESSIONS PART VI, LINE 3: PATIENTS MAY OBTAIN A COPY OF THE FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY OF THE POLICY, AND A FINANCIAL ASSISTANCE APPLICATION FREE OF CHARGE (I) BY MAIL BY CALLING 402-887-6286, (II) BY E-MAIL (UPON PATIENT ELECTION) BY E-MAILING PATIENTFINANCIALCOUNSELOR@AMHNE.ORG, (III) BY DOWNLOAD FROM WWW.AMHNE.ORG/PAGES/FINANCIALASSISTANCE/INDEX.HTML, OR (IV) IN PERSON AT (A) THE EMERGENCY ROOM, (B) ANY ADMISSION AREAS, OR ( C) THE OFFICE OF THE PATIENT FINANCIAL COUNSELOR LOCATED NEAR THE HOSPITAL BUSINESS OFFICE. ANTELOPE MEMORIAL HOSPITAL ALSO INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. IF A PATIENT SUBMITS A COMPLETED FINANCIAL ASSISTANCE APPLICATION DURING THE APPLICATION PERIOD AND THE HOSPITAL DETERMINES THAT THE PATIENT MAY BE ELIGIBLE FOR PARTICIPATION IN MEDICAID, THE HOSPITAL WILL NOTIFY THE PATIENT IN WRITING OF SUCH POTENTIAL ELIGIBILITY AND REQUEST THAT THE PATIENT TAKE STEPS NECESSARY TO ENROLL IN SUCH PROGRAM. IN SUCH CIRCUMSTANCES THE HOSPITAL WILL DELAY THE PROCESSING OF THE PATIENT'S FINANCIAL ASSISTANCE APPLICATION UNTIL THE PATIENT'S APPLICATION FOR MEDICAID IS COMPLETED, SUBMITTED TO THE REQUISITE GOVERNMENTAL AUTHORITY, AND A DETERMINATION HAS BEEN MADE. PART VI, LINE 4: ANTELOPE MEMORIAL HOSPITAL IS THE ONLY ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA DUE TO THE CLOSURE OF TILDEN COMMUNITY HOSPITAL. ANTELOPE MEMORIAL HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON AND PIERCE. THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT PROJECTS THE TOTAL SERVICE POPULATION TO BE AROUND 45,000 RESIDENTS, OF WHICH 11.5% ARE BELOW THE POVERTY LEVEL. THE POPULATION IS DECREASING, AND OVER 50% OF RESIDENTS ARE OVER THE AGE OF 45. PART VI, LINE 5: ANTELOPE MEMORIAL HOSPITAL PROMOTES THE HEALTH OF ITS COMMUNITY BY PROVIDING A COMMUNITY-BASED WELLNESS PROGRAM THAT ENCOURAGES INDIVIDUALS TO LIVE A HEALTHIER LIFESTYLE. AMH OFFERS A VARIETY OF EQUIPMENT AND GUIDANCE TO ASSIST COMMUNITY MEMBERS IN REACHING THEIR INDIVIDUAL WELLNESS GOALS, SUCH AS PREVENTING DISEASES AND CREATING A HEALTHIER COMMUNITY. AMH OFFERS ITS COMMUNITY DIABETES EDUCATION CLASSES, SMOKING CESSATION EDUCATION, AND OUTPATIENT GROUP THERAPY PROGRAMS DESIGNED FOR THOSE STRUGGLING WITH SYMPTOMS OF DEPRESSION AND ANXIETY.AMH ALSO COLLABORATES WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS TO FOCUS ON SUBSTANCE ABUSE PREVENTION, MOST RECENTLY PROVIDING DRUG RECOGNITION AND AWARENESS TRAINING. FORM 990, PART VI, LINE 7: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE, HOWEVER A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. X X 0 0 0 0 0 0 0 0 0 ROGER RUDLOFF MD PHYSICIAN 455934 0 2269 0 0 0 15642 0 17383 0 491228 0 0 0 TROY DAWSON MD PHYSICIAN 382760 0 8785 0 0 0 15642 0 25913 0 433100 0 0 0 JOSHUA THOENDEL MD PHYSICIAN 378764 0 7171 0 0 0 15642 0 25913 0 427490 0 0 0 KELLI OSBORN MD PHYSICIAN 286609 0 12215 0 0 0 15642 0 25913 0 340379 0 0 0 DIANE BRUGGER ADMINISTRATOR/CEO 297328 0 2519 0 0 0 13414 0 17383 0 330644 0 0 0 MARTHA NELSON CFO 213592 0 2251 0 0 0 8800 0 17383 0 242026 0 0 0 TANYA SHARP CCOO 170202 0 2294 0 0 0 0 0 25913 0 198409 0 0 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, COMPRISED OF THE PRESIDENT, VICE PRESIDENT, SECRETARY AND TREASURER, SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO AND CEO REVIEW THE FORM 990 AND THE ADMINISTRATOR 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. ANY POTENTIAL CONFLICTS SHOULD BE DICLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY PERSON HAVING A CONFLICT OF INTEREST OR POSSIBLE CONFLICT IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER INFLUENCE ON THE MATTER. 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 ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,669,529. MANAGEMENT AND GENERAL EXPENSES 755,582. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,425,111. THERAPIST FEES: PROGRAM SERVICE EXPENSES 966,828. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 966,828. MRI FEES: PROGRAM SERVICE EXPENSES 33,280. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 33,280. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 66,675. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 66,675. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 53,121. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,121. FORM 990, PART XII, LINE 2C: THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. HILLTOP COMMUNITY PHARMACY LLC 108 W 11TH ST NELIGH NE 68756 992418371 PHARMACY NE 1840016 626489 ANTELOPE MEMORIAL HOSPITAL