2018-05-14T18:03:18-05:00 2017-06-30 461497033 EKS&H LLLP 8181 E TUFTS AVENUE SUITE 600 DENVER CO 802372579 990 2016-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 9702377000 2018-05-11 1 DORI J EGGETT P00645252 3037409400 2016 2022-09-23 18:48:47Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 1201899581 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES THROUGH LEARNING, HEALING, DISCOVERY, AND THROUGH HUMAN CONNECTION. 11 10 4544 540 7136847 6141000 1749929 2840052 497070556 577191100 34325141 22577481 12353000 12670163 545498626 615278796 33530461 41334657 0 0 204165832 216412492 0 0 0 232570715 259555547 470267008 517302696 75231618 97976100 3847835066 4835353781 2784126390 3498192542 1063708676 1337161239 WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 0 471507387 41334657 577191100 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2017, PVHC RECORDED 57,037 PATIENT DAYS, 15,744 ADMISSIONS, 282,182 OUTPATIENT VISITS, 64,736 EMERGENCY VISITS, 2,098 DELIVERIES, 4,129 INPATIENT SURGERIES, AND 5,707 OUTPATIENT SURGERIES. 471507387 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 1 212 0 1 4544 1 1 1 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X STEPHANIE DOUGHTY 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 MIKE DELLENBACH BOARD CHAIR 1.00 2.00 X X 0 0 0 CHRIS OSBORN VICE BOARD CHAIR 1.00 2.00 X X 0 0 0 CHRISTINE CHIN PAST BOARD CHAIR 1.00 2.00 X 0 0 0 LISA CLAY BOARD MEMBER 1.00 2.00 X 0 0 0 DOUG ERION BOARD MEMBER 1.00 2.00 X 0 0 0 TESS HEFFERNAN BOARD MEMBER 1.00 2.00 X 0 0 0 DENNIS HOUSKA BOARD MEMBER 1.00 2.00 X 0 0 0 JIM PARKE BOARD MEMBER 1.00 2.00 X 0 0 0 JAMES SPROWELL MD BOARD MEMBER 1.00 2.00 X 0 0 0 DAN STROH BOARD MEMBER 1.00 2.00 X 0 0 0 KEVIN UNGER PRESIDENT/CEO 25.00 26.00 X X 626478 626478 115260 STEPHANIE DOUGHTY CFO 25.00 26.00 X 305967 305967 62905 DR STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 25.00 25.00 X 228092 228092 54497 DONNA PODUSKA CNO 50.00 X 263226 0 36903 MARILYN SCHOCK COO 25.00 25.00 X 192754 192754 44581 DR JOSEPH GOTTFRIED PSYCHIATRIST 50.00 X 256422 0 48653 DR HERMANN MORENO PSYCHIATRIST 50.00 X 263898 0 47365 DR DAVID SEHR PSYCHIATRIST 50.00 X 260523 0 49005 KENNETH WATANABE PSYCHIATRIST 50.00 X 296809 0 49500 DR JANELL WOZNIAK CLINICAL DIRECTOR 50.00 X 291661 0 41896 RUSSELL WOOLEY VP OPERATIONS, FORMER 0.00 X 97265 97265 27347 3083095 1450556 577912 158 1 1 0 UNIVERSAL PROTECTION SERVICE PO BOX 31001-2374 PASADENA CA 91110 SECURITY 3035330 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY RD 300 FT COLLINS CO 80528 MEDICAL 2237528 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE 300 FT COLLINS CO 80524 MEDICAL 1955965 SUMMIT PATHOLOGY 5802 WRIGHT DR LOVELAND CO 80538 MEDICAL 1851456 ARUP LABRORATORIES PO BOX 27964 SALT LAKE CITY UT 84127 MEDICAL 1465912 42 1344348 1177462 318242 1060184 2840052 NET PATIENT SVC REV 900099 584462621 584462621 PROVIDER FEE INCOME 621400 22991257 22991257 DIETARY SVC INCOME 900099 2161245 2161245 JOINT VENTURE 621400 -32547012 -32859744 312732 122989 107936 15053 577191100 15288622 15288622 945951 945951 10797733 1603452 2198835 1603452 8598898 0 8598898 6809062 1789836 588962280 72733 582244792 447313 6717488 -374580 6342908 6342908 389195 126393 262802 262802 MISCELLANEOUS REVENUE 621400 2478566 2478566 0 EHR REVENUE 624100 933401 933401 INCOME TAX REFUND 624100 396496 396496 3808463 615278796 578114037 7136847 27187860 41334657 41334657 1746148 721777 1024371 165695661 152990631 12705030 27649967 25382806 2267161 19157448 17586632 1570816 2163268 1985891 177377 41805 41805 72156 1305 70851 41744 41744 2181150 2181150 26516593 10859416 15657177 3209178 3132272 76906 4889479 4514442 375037 9164638 8229907 934731 3198644 2583912 614732 1024082 786420 237662 712805 640456 72349 7465458 7465458 23522024 22336307 1185717 2285392 138171 2147221 MEDICAL SUPPLIES 118591931 118235207 356724 UBI TAXES 2155911 2155911 PROVIDER FEE EXPENSE 23301078 23301078 BAD DEBT 18171497 18171497 13009982 11109145 1900837 517302696 471507387 45795309 0 25306411 101680312 1729412 1910410 54166356 59387946 44554 44807 8574425 9500542 5914506 7126559 669913042 360277831 295390465 309635211 909389700 1039103384 26544710 26424622 2520774527 3280539988 3847835066 4835353781 84155664 85287624 615274 1494757 204394246 196985054 21127201 19705807 78767 85807 2473755238 3194633493 2784126390 3498192542 X 1063708676 1337161239 1063708676 1337161239 3847835066 4835353781 X 97976100 86282154 89194309 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 41744 0 0 41744 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 11854028 3821556 845737 1407171 1817159 13296991 11242112 3051448 73951 720479 1793004 11854028 11287236 2977196 98459 1595156 1525623 11242112 10692037 4841525 985793 3756845 1455274 11287236 8938992 2680308 520466 565964 881765 10692037 0.48540 0.51460 1 1 1 58703442 58703442 281390646 119396566 161994080 97481548 71528107 25953441 179683699 126180852 53502847 52653707 43172306 9481401 309635211 INTERCOMPANY RECEIVABLE 3265071272 DEFERRED DEBT ISSUANCE COSTS 2704534 OTHER RECEIVABLES 5035104 DEFERRED PENSION OUTFLOW COSTS 7729078 3280539988 INTERCOMPANY PAYABLES 3179131660 ACCRUED INTEREST PAYABLE 1840529 OTHER DEFERRED EXPENSES 2401503 PENSION LIABILITIES 11259801 3194633493 720937395 86282154 3928680 90210834 630726561 2181150 -17628915 -15447765 615278796 500170395 3928680 3928680 496241715 2181150 18879831 21060981 517302696 PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 3,802,287. COGS REPORTED AS EXPENSE ON AFS 126,393. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,171,497. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 284,164. RENTAL EXP AS INCOME ON 990 12,621. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 15,053. INCOME TAX REFUND REDUCED EXPENSES ON AFS 396,496. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS -36,508,746. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 3,802,287. COGS REPORTED AS EXPENSE ON AFS 126,393. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,171,497. RENTAL EXP AS INCOME ON 990 12,621. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 15,053. CASH CONTRIBUTIONS FROM FOUNDATION NOT IN AFS REVENUE 284,164. INCOME TAX REFUND REDUCED EXPENSES ON AFS 396,496. 1 1 X 1 X 250.000000000000 1 X 1 0 1 1 306024 306024 0.00060 72824993 62900187 9924806 0.02000 21332007 18436727 2895280 0.00580 94463024 81336914 13126110 0.02640 3135424 224321 2911103 0.00590 5907150 784502 5122648 0.01030 8508294 5819870 2688424 0.00540 158200 111966 46234 0.00010 40784787 40784787 0.08210 58493855 6940659 51553196 0.10380 152956879 88277573 64679306 0.13020 147113 147113 0.00030 820 820 0.00000 210342 210342 0.00040 358275 358275 0.00070 1 20768786 162736134 236645729 -73909595 X 1 1 1 HARMONY SURGERY CENTER LLC AMBULATORY SURGERY 0.50000 0.50000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVICES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURGERY 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33000 0.67000 8 PVHS-ICM EHW LLC MEDICAL CLINIC 0.50000 0.50000 1 1 POUDRE VALLEY HOSPITAL 1024 S LEMAY FORT COLLINS CO 80524 X X X X X PHARMACY, LAB, CARDIOVASCULAR POUDRE VALLEY HEALTH CARE 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X SEE PART V, SECTION C X 1 15 1 SEE PART V, SECTION C 0 1 X 250.000000000000 400.000000000000 X X X X X 1 1 X X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5: TWO COMMUNITY MEETINGS WERE HELD DURING NOVEMBER 2015 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. PARTICIPANTS IDENTIFIED ADDITIONAL HEALTH ISSUES AND PROVIDED FEEDBACK AS TO HOW THE HOSPITALS MIGHT ADDRESS THEM. ATTENDEES REPRESENTED ORGANIZATIONS SERVING LOW-INCOME, UNINSURED AND MINORITY POPULATIONS. A LIST OF THE ORGANIZATIONS REPRESENTED IS INCLUDED AS AN APPENDIX TO THE CHNA REPORT. THE SECOND MEETING INCLUDED MEMBERS OF A COALITION SERVING LOW-INCOME, HISPANIC INDIVIDUALS. THE SYNOPSIS OF INFORMATION GATHERED DURING THESE MEETINGS IS INCLUDED IN AN APPENDIX OF THE 2016 CHNA REPORT. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6A: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2016 CHNA. THE GEOGRAPHIC SERVICE AREA FOR BOTH POUDRE VALLEY HOSPITAL & MEDICAL CENTER OF THE ROCKIES IS THE SAME. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6B: CENTENNIAL HIGH SCHOOL HEALTH CENTER POUDRE SCHOOL DISTRICT - WELLNESS TEAM THOMPSON SCHOOL DISTRICT TEAM WELLNESS & PREVENTION LUTHERAN FAMILY SERVICES THE MATTHEWS HOUSE CITY OF FORT COLLINS - HOUSING AUTHORITY FAMILY CENTER/LA FAMILIA HEALTH DISTRICT OF NORTHERN LARIMER COUNTY HOUSE OF NEIGHBORLY SERVICES LARIMER COUNTY FOOD BANK LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENT SALUD FAMILY HEALTH CENTER-FORT COLLINS SUMMITSTONE BEHAVIORAL HEALTH THE CENTER FOR FAMILY OUTREACH VIDA SANA COALITION COLUMBINE HEALTH SYSTEM DEMENTIA FRIENDLY COMMUNITY PARTNERSHIP FOR AGE-FRIENDLY COMMUNITIES SHARING THE CARE CAMPAIGN UCHEALTH - COMMUNITY HEALTH IMPROVEMENT UNITED WAY OF LARIMER COUNTY WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PART V, SECTION B, LINE 7A:HTTPS://WWW.UCHEALTH.ORG/PAGES/ABOUT-UCHEALTH/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.ASPXPART V, SECTION B, LINE 10A:HTTPS://WWW.UCHEALTH.ORG/WP-CONTENT/UPLOADS/2016/11/COMHEA-COMMUNITYHEALTHNEEDSASSESSMENT-NORTH-INTERACTIVE.PDF POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 11: HEALTH NEED - ACCESS TO CARE FOR OLDER ADULTS, MINORITY AND LOW-INCOME INDIVIDUALS: BOTH POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDE A NO-COST COMMUNITY PARAMEDIC HOME BASED SERVICE WHICH PROVIDES CLINICAL REVIEW OF CHRONIC CONDITIONS TO HOME-BOUND OR FRAIL INDIVIDUALS. BOTH HOSPITALS ALSO PROVIDE AN RN HOME VISIT PROGRAM, SERVING MEDICAID-ELIGIBLE WOMEN WITH POST-PARTUM NEWBORN ASSESSMENTS AND LIMITED CASE MANAGEMENT SERVICES. COMMUNITY CASE MANAGEMENT NURSES PROVIDE NO-COST IN-HOME SERVICES TO PERSONS NEEDING ASSISTANCE IN MANAGING CHRONIC DISEASE. HEALTH NEED - CARDIOVASCULAR DISEASE PREVENTION AND CONTROL: BOTH HOSPITALS SUPPORT A SCHOOL-BASED HEART DISEASE SCREENING AND EDUCATION PROGRAM FOR ELEMENTARY, MIDDLE AND HIGH SCHOOL-AGED YOUTH; CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS PROVIDE COUNSELING AND ACHIEVE INCREASED SELF-EFFICACY BY PARTICIPANTS TO MANAGE THEIR CONDITION; COMMUNITY HEALTH WORKER MODEL PROVIDES NO-COST, COMMUNITY-BASED HEART DISEASE ASSESSMENT AND REFERRAL TO SCREENING SERVICES TO LOW-INCOME, OLDER ADULT AND/OR MINORITY POPULATIONS. HEALTH NEED - SUICIDE PREVENTION / SUBSTANCE ABUSE PREVENTION & TREATMENT: PLANNING TEAM FORMED TO DEVELOP METHODS TO IMPLEMENT EVIDENCE-BASED ZERO SUICIDE INITIATIVE AT BOTH HOSPITALS RESULTING IN ADDITIONAL STAFF RECRUITED TO TRAIN NON-BEHAVIORAL STAFF ON SUICIDE PREVENTION AND ALSO FOR BEHAVIORAL HEALTH PREVENTIVE SERVICES; SEVERAL NO-COST CARE COORDINATION INITIATIVES WORK TO REMOVE BARRIERS TO BEHAVIORAL HEALTH CARE FOR VULNERABLE POPULATIONS (E.G. CHILDREN IN FOSTER CARE OR AT RISK FOR REMOVAL FROM BIOLOGICAL HOME / LOW-INCOME, MEDICAID-ELIGIBLE COMMUNITY MEMBERS) BY ENROLLING INDIVIDUALS INTO A PATIENT-CENTERED MEDICAL HOME, ENSURING TIMELY ACCESS TO BEHAVIORAL HEALTH SERVICES, REMOVING TRANSPORTATION OR CHILD-CARE BARRIERS, ETC. FULL DESCRIPTION OF ALL INITIATIVES IS INCUDED IN THE IMPLEMENTATION STRATEGY REPORT ATTACHED. 2017 PROGRESS REPORT ALSO ATTACHED.PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4 70 1 - HARMONY CAMPUS MOB 2121 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICES, ONCOLOGY, HCOR, CANCER CENTER,NCPC, SSOR, RHEUMATOLOGY 2 - HARMONY CAMPUS AMBULATORY CARE CENTER 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE 3 - UCHEALTH HARMONY EMERGENCY 4630 SNOW MESA DRIVE FORT COLLINS CO 80528 HARMONY ED 4 - UCHEALTH-LONGMONT 1925 MOUNTAIN VIEW AVE LONGMONT CO 80501 PHYSICIAN OFFICES 5 - UCHEALTH PHYSICIAN CLINICS 1400 E BOULDER STREET COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES 6 - MCR NORTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES, ONCOLOGY, SSOR, OHS 7 - UCHEALTH GREELEY MEDICAL CLINIC 1900 16TH STREET GREELEY CO 80631 PHYSICIAN OFFICES, LAB, RADIOLOGY & ONCOLOGY, URGENT CARE 8 - UCHEALTH BRIARGATE 4110 BRIARGATE PARKWAY COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 9 - UCHEALTH PEAKVIEW MEDICAL CENTER 5881 W 16TH STREET GREELEY CO 80634 PHYSICIAN OFFICES, LAB & RADIOLOGY 10 - MCR SOUTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES, HCOR, CARDIAC REHAB, SLEEP LAB, BRAIN & SPINE 11 - UCHEALTH PENNOCK PLACE 1025 PENNOCK PLACE FORT COLLINS CO 80524 PHYSICIAN OFFICES (FMC), BLOOD BANK 12 - UCHEALTH CHEYENNE MEDICAL SPECIALISTS 5050 POWDERHOUSE RD CHEYENNE WY 82009 PHYSICIAN OFFICES, NEUROLOGY, OHS, GI 13 - UCHEALTH REDSTONE 2315 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICE, UROLOGY, NEUROLOGY 14 - UCHEALTH PRINTERS PARK 175 S UNION BLVD COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES 15 - UCHEALTH SNOW MESA 4674 SNOW MESA DRIVE FORT COLLINS CO 80528 PHYSICIAN OFFICES, OHS 16 - UCHEALTH WESTBRIDGE 1107 S LEMAY FORT COLLINS CO 80524 PHYSICIAN OFFICES, SLEEP LAB, WEE STEPS 17 - UCHEALTH MEMORIAL NEUROSCIENCES 1725 BOULDER STREET SUITE 101 COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES 18 - UCHEALTH-FIRESTONE 660 FIRESTONE BLVD FIRESTONE CO 80504 PHYSICIAN OFFICES NEW BUILDING 19 - UCHEALTH PROSPECT MEDICAL PLAZA 1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524 PHYSICIAN OFFICES, OUTPATIENT REHAB, INT MEDICINE, ENDOCRINOLOGY 20 - CENTRE AVE HEALTH AND REHAB-JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB 21 - UCHEALTH URGENT CARE CIRCLE SQUARE 2767 JANITELL ROAD COLORADO SPRINGS CO 80906 PHYSICIAN OFFICES 22 - MOUNTAIN CREST BEHAVIORAL HEALTH 4601 CORBETT DR FORT COLLINS CO 80528 BEHAVIORAL HEALTH 23 - UCHEALTH URGENT CARE POWERS 4323 INTEGRITY CENTER POINT COLORADO SPRINGS CO 80917 PHYSICIAN OFFICES 24 - UCHEALTH WINDSOR MEDICAL CENTER 1455 MAIN STREET WINDSOR CO 80550 PHYSICIAN OFFICES, RADIOLOGY, LAB 25 - UCHEALTH OB-GYN CLINIC 1715 61ST AVENUE GREELEY CO 80631 PHYSICIAN OFFICES, OB-GYN 26 - SURGERY CENTER OF FT COLLINS-JV 1100 E PROSPECT RD FORT COLLINS CO 80524 SURGERY CENTER 27 - UCHEALTH PHYSICIAN CLINICS 525 N FOOTE AVE SUITE 302 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES 28 - UROLOGY CENTER OF THE ROCKIES 3520 E 15TH STREET LOVELAND CO 80538 PHYSICIAN OFFICES, UROLOGY 29 - UCHEALTH PRIMARY AND URGENT CARE 131 STANLEY DR ESTES PARK CO 80517 PHYSICIAN OFFICES 30 - UCHEALTH EXPRESS LAB 1025 GARFIELD ST SUITE C FORT COLLINS CO 80524 EXPRESS LAB, THERAPEUTIC ENDOSCOP 31 - UCHEALTH CHILDREN'S THERAPY 1500 S LEMAY FORT COLLINS CO 80526 THERAPY 32 - UCHEALTH NORTH SPRINGS FAMILY MEDICINE & 8540 SCARBOROUGH DRIVE COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 33 - UCHEALTH PRIMARY CARE AT BRIARGATE 8890 N UNION BLVD SUITE 100B COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 34 - UCHEALTH RANGEVIEW 2695 ROCKY MOUNTAIN AVE 200 LOVELAND CO 80538 NEUROLOGY 35 - UCHEALTH PRIMARY CARE 2975 GINNALA DRIVE LOVELAND CO 80538 PHYSICIAN OFFICES 36 - UCHEALTH OCCUPATIONAL MEDICINE CLINIC- G 1035 GARDEN OF THE GODS 120 COLORADO SPRINGS CO 80907 OCC HEALTH 37 - UCHEALTH PRIMARY CARE - FRONT RANGE 5265 N ACADEMY BLVD SUITE 1800 COLORADO SPRINGS CO 80918 PHYSICIAN OFFICES 38 - UCHEALTH PRIMARY CARE - ROCKRIMMON 6615 DELMONICO DRIVE COLORADO SPRINGS CO 80919 PHYSICIAN OFFICES 39 - UCHEALTH URGENT CARE VOYAGER PARKWAY 13445 VOYAGER PARKWAY COLORADO SPRINGS CO 80921 PHYSICIAN OFFICES 40 - UCHEALTH SCOTTSBLUFF 2 W 42ND ST 2200 SCOTTSBLUFF NE 69361 PHYSICIAN OFFICES 41 - UCHEALTH PRIMARY CARE-STERLING 620 IRIS DRIVE STERLING CO 80751 PHYSICIAN OFFICES 42 - UCHEALTH NORTH LOVELAND 3830 N GRANT AVE LOVELAND CO 80538 PHYSICIAN OFFICES 43 - COLUMBINE POUDRE HOMECARE-JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE 44 - UCHEALTH WEST LOVELAND 3850 N GRANT AVE LOVELAND CO 80538 URGENT CARE 45 - WALK IN CLINIC 2211 S COLLEGE AVE FORT COLLINS CO 80525 WALK IN CLINIC 46 - UCHEALTH SUNFLOWER FAMILY MEDICINE 1730 N CORONA STREET COLORADO SPRINGS CO 80907 PHYSICIAN OFFICES 47 - UCHEALTH WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 OUTPATIENT REHAB, CLINICAL EDUCATION, MED FITNESS CENTER 48 - THE VEIN AND LASER CENTER-JV 2008 CARIBOU DRIVE FORT COLLINS CO 80525 PHYSICIAN OFFICES 49 - UCHEALTH PRIMARY CARE-MONUMENT 15854 JACKSON CREEK PARKWAY SUITE 120 MONUMENT CO 80132 PHYSICIAN OFFICES 50 - UCHEALTH FORT MORGAN 1000 LINCOLN STREET 207 FORT MORGAN CO 80701 PHYSICIAN OFFICES 51 - EYE LASER CENTER OF N COLORADO-JV 1725 EAST PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES 52 - UCHEALTH URGENT CARE THORNTON 13631 COLORADO BLVD THORNTON CO 80602 PHYSICIAN OFFICES 53 - UCHEALTH FALCON MEDICAL CENTER 11605 MERIDIAN MARKET VIEW 184 FALCON CO 80831 PHYSICIAN OFFICES, OCC HEALTH, PRIMARY CARE 54 - UCHEALTH STEELE STREET 311 STEELE STREET DENVER CO 80206 PHYSICIAN OFFICES 55 - UCHEALTH - LARAIME 3116 WILLET DRIVE LARAMIE WY 82070 PHYSICIAN OFFICES 56 - UCHEALTH STEAMBOAT 940 CENTRAL PARK DR 290 STEAMBOAT SPRINGS CO 80487 PHYSICIAN OFFICES 57 - UCHEALTH ESTES PARK 555 PROSPECT AVE ESTES PARK CO 80517 PHYSICIAN OFFICES 58 - UCHEALTH SIDNEY 1625 DORWART DRIVE SIDNEY NE 69162 PHYSICIAN OFFICES 59 - UCHEALTH HEART AND VASCULAR CRAIG 595 RUSSELL STREET CRAIG CO 81625 PHYSICIAN OFFICES 60 - UCHEALTH CASTLE ROCK 4404 BARRANCA LANE 101 CASTLE ROCK CO 80104 PHYSICIAN OFFICES 61 - UCHEALTH CANCER CARE AND HEMATOLOGY CLIN 910 S MAIN ST YUMA CO 80759 PHYSICIAN OFFICES 62 - UCHEALTH CARDIOLOGY BRIDGEPORT 1313 S STREET BRIDGEPORT NE 69336 PHYSICIAN OFFICES 63 - UCHEALTH CV SURGERY 2030 MOUNTAIN VIEW AVE 540 LONGMONT CO 80501 PHYSICIAN OFFICES 64 - UCHEALTH CANCER CARE AND HEMATOLOGY CLIN 1017 W 7TH STREET WRAY CO 80758 PHYSICIAN OFFICES 65 - UCHEALTH CANCER CARE AND HEMATOLOGY CLIN 1101 E JOHNSON ST HOLYOKE CO 80734 PHYSICIAN OFFICES 66 - PHLEBOTOMY STATION 1107 SOUTH LEMAY AVE FORT COLLINS CO 80526 LAB DRAWS 67 - PHLEBOTOMY STATION 1113 OAKRIDGE DRIVE FORT COLLINS CO 80525 LAB DRAWS 68 - PHLEBOTOMY STATION 2001 S SHIELDS FORT COLLINS CO 80526 LAB DRAWS 69 - PHLEBOTOMY STATION 2025 BIG HORN DRIVE FORT COLLINS CO 80525 LAB DRAWS 70 - PHLEBOTOMY STATION 3519 RICHMOND DRIVE FORT COLLINS CO 80526 LAB DRAWS PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $20,768,786 PART II, COMMUNITY BUILDING ACTIVITIES: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 113,642,637CENTER AVE COST REPORT: 2,994,041COLUMBINE HOMECARE COST REPORT: 1,230,507PVHC DISALLOWED PROGRAMS: 976,909JOINT VENTURES: 43,892,040TOTAL TO LINE 5: 162,736,134PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2016 COST REPORT AGGREGATED WITH DISREGARDED ENTITIES AND OWNERSHIP PORTIONS OF JOINT VENTURES. PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 152,864,931CENTRE AVE COST REPORT: 5,655,301COLUMBINE HOMECARE COST REPORT: 1,593,970PVHC DISALLOWED PROGRAMS: 1,390,516JOINT VENTURES: 75,141,011TOTAL TO LINE 6: 236,645,729 PART III, LINE 8: APPROXIMATELY 26.4% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART III, LINE 9B: PATIENT PROVIDES DOCUMENTATION BASED ON FINANCIAL ASSISTANCE POLICY GUIDELINES, REVIEWED BY FINANCIAL COUNSELING TEAM. UPON APPROVAL OR DENIAL OF THE REQUEST FOR CHARITABLE AID FROM THE FAC TEAM, THE PATIENT WILL BE ADVISED OF THE DECISION. THE BILL IS PARTIALLY OR TOTALLY ADJUSTED AS APPROVED BY THE FAC TEAM, NO FURTHER COLLECTION PROCESS WITH THE PATIENT. FOR ANY PORTION NOT ADJUSTED OFF, THE PROPER SEQUENCE OF ATTEMPTS TO COLLECT ARE FOLLOWED. FINAL ASSIGNMENT OF THE BILL IS TO A COLLECTION AGENCY. PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS). PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE ED, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. PART VI, LINE 4: POUDRE VALLEY HOSPITAL IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTHCARE TO HEALTH.BASED IN NORTHERN COLORADO, PVH PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVH IS A PART OF THE UCHEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, UCHEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS. WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. PART VI, LINE 7, REPORTS FILED WITH STATES CO 1 ALLIANCE FOR SUICIDE PREVENTION 1100 POUDRE RIVER DRIVE SUITE B FORT COLLINS CO 80525 841194619 501(C )(3) 5200 SEE SCH I, PART IV AMERICAN CANCER SOCIETY 8221 W 20TH STREET GREELEY CO 80634 131788491 501(C )(3) 33000 SEE SCH I, PART IV BOOK TRUST 789 SHERMAN STREET SUITE 300A DENVER CO 80203 204124164 501(C )(3) 9050 SEE SCH I, PART IV BOY SCOUTS OF AMERICA - LONGS PEAK COUNCIL 1900 16TH STREET GREELEY CO 80631 840253710 501(C )(3) 7000 SEE SCH I, PART IV CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522 846000587 GOVERNMENT 12000 SEE SCH I, PART IV COLO NONPROFIT DEVELOPMENT CENTER 789 SHERMAN STREET SUITE 250 DENVER CO 80203 841493585 501(C )(3) 20000 SEE SCH I, PART IV DOWNTOWN BUSINESS ASSOCIATION 19 OLD TOWN SQUARE 230 FORT COLLINS CO 80524 840535419 501(C )(3) 10000 SEE SCH I, PART IV FOOD BANK OF LARIMER COUNTY 1301 BLUE SPRUCE DRIVE FORT COLLINS CO 80524 742336171 501(C )(3) 9000 SEE SCH I, PART IV GREELEY PHILHARMONIC ORCHESTRA PO BOX 1535 GREELEY CO 80632 846031376 501(C )(3) 82900 SEE SCH I, PART IV HEALTH CENTER FOUNDATION 645 OSAGE STREET SIDNEY NE 69162 470686476 501(C )(3) 6000 SEE SCH I, PART IV HOPE LIVES 2629 REDWING ROAD 260 FORT COLLINS CO 80526 841595472 501(C )(3) 5400 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 NORTH 30TH STREET LARAMIE WY 82072 836000188 501(C )(3) 9500 SEE SCH I, PART IV LARIMER COUNTY PARTNERS 530 S COLLEGE AVENUE 1 FORT COLLINS CO 80524 742486211 501(C )(3) 24000 SEE SCH I, PART IV LOVELAND CHAMBER OF COMMERCE 5400 STONE CREEK CIRCLE LOVELAND CO 80538 840254565 501(C )(6) 5700 SEE SCH I, PART IV NOCO UNIFY 4627 W 20TH STREET B GREELEY CO 80634 208575428 501(C )(3) 13400 SEE SCH I, PART IV PROJECT SELF SUFFICIENCY 375 W 37TH STREET LOVELAND CO 80538 841206341 501(C )(3) 5500 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE ST 102 FORT COLLINS CO 80524 846031503 501(C )(3) 35562 SEE SCH I, PART IV UNITED WAY OF WELD COUNTY PO BOX 1944 GREELEY CO 80632 846011918 501(C )(3) 36553 SEE SCH I, PART IV VOICES CARRY CHILD ADVOCACY CENTER 5529 S TIMBERLINE ROAD FORT COLLINS CO 80528 841324009 501(C )(3) 8600 SEE SCH I, PART IV YAMPA VALLEY MEDICAL CENTER FOUNDATION 1024 CENTRAL PARK DRIVE STEAMBOAT SPRINGS CO 80487 311806773 501(C )(3) 18000 SEE SCH I, PART IV PVH FOUNDATION 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 1335816 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 E 17TH PL AURORA CO 80045 846000555 GOVERNMENT 3762149 SEE SCH I, PART IV UCHEALTH MEDICAL GROUP 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 800348943 501(C )(3) 35413154 SEE SCH I, PART IV 21 2 PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION I, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X 1 1 X X X X 1 0 0 0 0 0 0 0 0 KEVIN UNGER PRESIDENT/CEO 251527 251527 368078 368078 6873 6873 47953 47952 9678 9677 684109 684107 0 0 STEPHANIE DOUGHTY CFO 239840 239840 63771 63771 2356 2356 25451 25451 6002 6001 337420 337419 0 0 DR STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 177662 177662 44840 44840 5590 5590 19982 19981 7267 7267 255341 255340 0 0 DONNA PODUSKA CNO 205550 0 52159 0 5517 0 26194 0 10709 0 300129 0 0 0 MARILYN SCHOCK COO 153343 153343 38626 38626 785 785 17506 17505 4785 4785 215045 215044 0 0 DR JOSEPH GOTTFRIED PSYCHIATRIST 249682 0 6193 0 547 0 25922 0 22731 0 305075 0 0 0 DR HERMANN MORENO PSYCHIATRIST 256787 0 6564 0 547 0 26475 0 20890 0 311263 0 0 0 DR DAVID SEHR PSYCHIATRIST 253731 0 6554 0 238 0 26230 0 22775 0 309528 0 0 0 KENNETH WATANABE PSYCHIATRIST 266481 0 29921 0 407 0 28785 0 20715 0 346309 0 0 0 DR JANELL WOZNIAK CLINICAL DIRECTOR 264438 0 26834 0 389 0 25979 0 15917 0 333557 0 0 0 RUSSELL WOOLEY VP OPERATIONS, FORMER 36118 36118 61147 61147 0 0 8442 8441 5232 5232 110939 110938 0 0 PART I, LINE 1A GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES, AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. PART I, LINE 4A RUSSELL WOOLEY RECEIVED A SEVERANCE PAYMENT OF $84,802. A COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26560000 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES A 841179794 914183BB3 2017-02-16 43493450 REFUNDING 2015A BONDS 0 0 0 D UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES B1B2 841179794 914183BD9 2017-02-16 57125000 REFUNDING 2015BC BONDS 0 0 0 A 50000000 4091637 653467 1459346 43795550 2005 0 1 1 1 B 26560000 2173477 347122 2204559 21834842 2005 1 0 1 1 C 43493450 43493450 2017 1 0 1 1 D 57125000 97273 57027727 2017 1 0 1 1 A 0 1 0 0 0.00000 0.00000 0 0 1 B 0 1 0 0 0.00000 0.00000 0 0 1 C 0 1 0 0 0.00000 0.00000 0 0 1 D 0 1 0 0 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 1 0 0 0 1 CITI 10.000000000000 0 0 0 0 1 D 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 SCHEDULE K, PART I, COLUMN E BOND ISSUE PRICE THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH A RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 80389: $83,000,000. SCHEDULE K, PART IV, LINE 2C THE REBATE CALCULATION WAS PERFORMED IN APRIL 2015 FOR BOND ISSUANCES A AND B. A UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES C1C2 841179794 914183BA5 2017-02-16 18406000 NEW CONSTRUCTION 0 0 0 A 18406000 7095250 55315 11255436 2017 0 0 0 1 A 0 1 0 0 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 X MEDICAL EQUIPMENT 61 1060184 FMV 0 0 0 FORM 990, PART I, LINE 6 PVH HAS 540 ACTIVE VOLUNTEERS IN FISCAL YEAR 2017. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEENS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 UCHEALTH CONTRACTS WITH HAYGROUP FOR EXECUTIVE COMPENSATION CONSULTING SERVICES. ON OUR BEHALF THE HAYGROUP COLLECTS AND REVIEWS COMPENSATION LEVELS FROM LIKE ORGANIZATION FOR LIKE JOBS AND PROVIDES UCHEALTH WITH THE COMPARATIVE MARKET DATA. THE DATA IS SUBMITTED TO THE CHIEF HUMAN RESOURCES OFFICER WHO ADVISES THE SYSTEM PRESIDENT AND CEO ON COMPENSATION DECISIONS FOR SENIOR EXECUTIVES. BASED ON THE MARKET DATA, THE SYSTEM PRESIDENT AND CEO DETERMINES THE SALARY OF THE ENTITY CEO'S COMPENSATION ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. FORM 990, PART XI, LINE 9: MCR DISTRIBUTIONS TO PVH 52,685,563. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 36,508,746. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO -16785 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 7868622 30893301 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 657338 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 2176867 3159602 0 0 0.50000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED -327154 449736 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 275512 712708 0 0 0.50000 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FORT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 31765 45963 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FORT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 7343494 12660041 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED -75674 674921 0 1 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FORT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED 3529 33713 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 539026 1837281 0 0 0.46000 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 485367 1031722 0 0 0.26000 POUDRE VALLEY MEDICAL GROUP LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 MEDICAL SERVICES CO N/A RELATED -35797120 37707192 0 1 0.99000 PVHS-ICM EHW 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 463311308 MEDICAL SERVICES CO N/A RELATED 3486 191157 0 0 0.50000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A UNRELATED 154991 84380 0 0 0.14300 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO PVHC C 824747 1443564 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 1 1 HARMONY SURGERY CENTER A 953198 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 625341 TRANSACTION TOTAL HARMONY SURGERY CENTER S 1925000 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 145700 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 7588549 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 8979597 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 4496038 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES S 52685563 TRANSACTION TOTAL PVHMCR FOUNDATION B 1335816 TRANSACTION TOTAL PVHMCR FOUNDATION C 1344346 TRANSACTION TOTAL PVHMCR FOUNDATION L 58871 TRANSACTION TOTAL PVHMCR FOUNDATION N 52080 TRANSACTION TOTAL INNOVATION ENTERPRISES A 119169 TRANSACTION TOTAL INNOVATION ENTERPRISES A 255599 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 35413154 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 2077768 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 4751153 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC L 5133691 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC N 2967482 TRANSACTION TOTAL