2018-09-04T15:40:34-05:00 2017-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD SUITE 501 TUCSON AZ 85711 990 2016-07-01 860208451 NORTHERN COCHISE COMMUNITY HOSPITAL INC NORT 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ROLAND KNOX CEO 5203843541 2018-06-18 1 DAVID B BARBER CPECFECGMA P00348638 5206248229 2018-06-18 2016 2022-09-23 18:48:47Z X ROLAND KNOX 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 19304517 0 X WWW.NCCH.COM X 1966 AZ TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 8 8 214 28 0 -1249 1878127 2045210 17133975 17149413 -20091 -3873 24853 108612 19016864 19299362 0 0 0 0 8654335 8437973 0 0 0 9472493 10086619 18126828 18524592 890036 774770 6367063 7584573 2554710 2997450 3812353 4587123 TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 0 0 11793693 17149413 THE HOSPITAL PROVIDES HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF AGE, RACE, OR ABILITY TO PAY. SERVICES INCLUDE, BUT ARE NOT LIMITED TO, EMERGENCY ROOM, PHYSICAL THERAPY, SPEECH THERAPY, RESP THERAPY, CT SCAN, MRI, RURAL HEALTH CLINIC, LABORATORY SERVICE, AND OTHER HEALTHECARE SERVICES. 11793693 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 67 0 1 214 1 1 1 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X X THE ORGANIZATION 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ROLAND KNOX EX-OFFICIO DIRECTOR, CEO 40.00 X X 191771 0 11489 STEVE METTS VICE-CHAIRMAN 1.00 X 0 0 0 DR JAMES MALONE CHAIRMAN 1.00 X 0 0 0 CAROL DUNAGAN DIRECTOR 1.00 X 0 0 0 KATHY COOK BOARD SECRETARY 1.00 X 0 0 0 E RICHARD SINGER DIRECTOR 1.00 X 82152 0 0 DR DAWN WALKER DIRECTOR 1.00 X 3862 0 0 WINFIELD THOMAS DIRECTOR 1.00 X 0 0 0 ELIZABETH KUHN NURSE PRACTITIONER 40.00 X 152938 0 11520 HELEN ROWE PHYSICAL THERAPIST 40.00 X 102415 0 2252 LAUREL KIBLER ANP - PROVIDER 40.00 X 186395 0 67 KIMBER AGUIRRE DIRECTOR OF PATIENT FINANCIAL SERVICE 40.00 X 105029 0 16726 PAMELA NOLAND DIRECTOR OF NURSING 40.00 X 107515 0 5407 932077 0 47461 6 0 1 0 ANTHONY LLEWELLYN MD PLC 5782 PLACITA DELEITE TUCSON AZ 85750 PHYSICIAN 388623 JOSHUA DOPKO MD 3697 PINNACLE COURT SIERRA VISTA AZ 85650 PHYSICIAN 334545 HISHAM HAMAM MD ELHAM MEDICAL INTERNAT PO BOX 12578 TUCSON AZ 85732 HOSPITALIST 284500 JEFFERY B BUSHMAN PO BOX 1115 WILCOX AZ 85644 PHYSICIAN 249960 MARK W KLEVE MD 6378 VANISHING POINTE WAY TUCSON AZ 85746 PHYSICIAN 116176 6 100537 1935738 8935 2045210 PATIENT SERVICE REVENUE 900099 16745437 16745437 OTHER SERVICE REVENUE 900099 403976 403976 17149413 1282 1282 63859 0 63859 63859 63859 5155 -5155 -5155 -5155 2890 100537 0 2890 2890 OTHER INCOME 900099 41863 41863 41863 19299362 17149413 0 104739 X 352139 88845 263294 6762776 5290605 1472171 92773 92773 730967 730967 499318 381135 118183 102762 102762 3830935 3502004 328931 49098 49098 46180 46180 19050 11043 8007 52301 52301 443587 195292 248295 352926 25649 327277 BAD DEBTS 1555203 1555203 MATERIALS AND SUPPLIES 1221286 1136133 85153 REPAIRS AND MAINTENANCE 881509 568351 313158 RENT-EQUIPMENT 489816 394829 94987 1041966 199807 842159 18524592 11793693 6730899 0 1295465 276888 1161520 2445520 1995085 1734599 128149 165565 147949 135945 8555247 6102961 1620395 2452286 18500 373770 6367063 7584573 1707503 1258119 847207 1739331 2554710 2997450 X 3767406 4542176 44947 44947 3812353 4587123 6367063 7584573 774770 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1945307 663742 1281565 329570 296443 33127 6038598 5142776 895822 241772 241772 2452286 X PART X, LINE 2: THE HOSPITAL HAS BEEN RECOGNIZED AS TAX EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES FOR INCOME TAXES SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS AND A MEASUREMENT CRITERIA FOR TAX BENEFITS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES AT JUNE 30, 2017 FOR UNCERTAIN INCOME TAX POSITIONS PURSUANT TO THE STANDARD. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT INCLUDE ANY INTEREST OR PENALTIES RELATED TO INCOME TAXES. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. 103427 100537 2890 103427 100537 2890 2890 1 1 X 1 X 0 0 1 1 0 1 1 48000 48000 0.00280 4523743 2221670 2302073 0.13570 4571743 2221670 2350073 0.13850 4571743 2221670 2350073 0.13850 68967 68967 0.00410 24824 24824 0.00150 155758 155758 0.00920 249549 249549 0.01480 1 1534134 4245404 5385005 -1139601 X 1 0 1 1 NORTHERN COCHISE COMMUNITY HOSPITAL 901 REX ALLEN DR WILLCOX AZ 85643 X X X X NORTHERN COCHISE COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.NCCH.NET X WWW.COCHISE.AZ.GOV X 1 16 1 WWW.NCCH.NET 0 1 X 100.000000000000 X X X X X 1 1 X X X 1 X 1 X 1 X X X 1 0 0 NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: THE ASSESSMENT PROCESS WAS INITIATED AND CHAIRED BY COCHISE HEALTH & SOCIAL SERVICES.17 AGENCIES PARTICIPATED IN THE CHNA PROCESS. A QUESTIONNAIRE WAS ALSO UTILIZED AS PART OF THE PROCESS. A TOTAL OF 2,376 SURVEYS WERE RETURNED. NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 6A: BENSON HOSPITALCOPPER QUEEN COMMUNITY HOSPITAL NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: COCHISE HEALTH & SOCIAL SERVICESLEGACY FOUNDAITON OF SOUTEHRN ARIZONA NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: SEE ATTACHED COMMUNITY HEALTH IMPLEMENTATION PLAN. 3 1 - SULPHUR SPRINGS MEDICAL CENTER 900 W SCOTT WILLCOX AZ 85643 MEDICAL CENTER 3 - SUNSITES MEDICAL CENTER 223 N FRONTAGE RD PEARCE AZ 85625 MEDICAL CENTER 4 - SPECIALTY CLINICS 900 W SCOTT WILLCOX AZ 85643 CLINIC PART I, LINE 3C: THE ORGANIZATION PROVIDES DISCOUNTED CARE BASED ON A CASE BY CASE EVALUATION. ALL INFORMATION IS REVIEWED BY THE PFS DIRECTOR AND COMPARED WITH THE POVERTY GUIDELINES AS WELL AS ALL OUTSTANDING MEDICAL EXPENSES. OTHER FACTORS WILL CONTRIBUTE TO THE FINAL DECISION. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), THAT IS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS 1,534,134. PART III, LINE 8: THE MEDICARE COST OF SERVICES IS BASED UPON DATA FROM THE HOSPITAL'S MEDICARE COST REPORT AND THE COST TO CHARGE RATIO INCLUDED THEREIN. X X X X X 0 0 0 1 0 0 0 0 0 ROLAND KNOX EX-OFFICIO DIRECTOR, CEO 191771 0 0 0 0 0 0 0 11489 0 203260 0 0 0 ELIZABETH KUHN NURSE PRACTITIONER 152938 0 0 0 0 0 0 0 11520 0 164458 0 0 0 LAUREL KIBLER ANP - PROVIDER 186395 0 0 0 0 0 0 0 67 0 186462 0 0 0 PART I, LINE 5 PURSUANT TO THE ORGANIZATION'S EMPLOYEE AGREEMENT WITH THE CEO, AN ANNUAL INCENTIVE BONUS MAY BE PAID. THIS BONUS IS DEPENDENT ON THE ORGANIZATION'S OVERALL FINANCIAL CONDITION AND THE CEO'S ACHIEVEMENT OF A VARIETY OF PREVIOUSLY ESTABLISHED GOALS RELATED TO COMMUNITY INVOLVEMENT, EMPLOYEE DEVELOPMENT, OPERATIONAL COMPLIANCE, INDUSTRY KNOWLEDGE, AND THE IMPLEMENTATION OF NEW PROGRAMS. NO BONUS PAYMENT WAS MADE IN THE YEAR 2016. FORM 990, PART VI, SECTION B, LINE 11B THE RETURN IS REVIEWED BY THE CEO AND MADE AVAILABLE TO THE BOARD OF DIRECTORS BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM ANNUALLY. THE FORMS ARE REVIEWED BY THE COMPLIANCE OFFICER FOR POTENTIAL CONFLICTS. ANY ACTUAL CONFLICTS ARE REVIEWED BY THE BOARD OF DIRECTORS. A PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED ON AN ANNUAL BASIS BY A COMPENSATION COMMITTEE BASED ON COMPARABILITY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 2,807,127. MANAGEMENT AND GENERAL EXPENSES 129,303. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,936,430. OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 694,877. MANAGEMENT AND GENERAL EXPENSES 199,628. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 894,505. FORM 990, PART XII, LINE 2C: THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT OR REVIEW PROCESS DURING THE YEAR. FORM 990, PAGE 1, QUESTION B, AMENDED RETURN THIS 990 IS AMENDED TO REFLECT 1099 COMPENSATION PAID TO ONE OF THE DIRECTORS OF THE BOARD, DR. SINGER, WHO RECEIVED $82,152 IN COMPENSATION FOR SERVICES RENDERED IN 2016. THAT CHANGE IS REPORTED ON PAGE 7 OF THE 990. THE STATEMENT OF FUNCTIONAL EXPENSES HAS BEEN UPDATED TO REFLECT FISCAL YEAR COMPENSATION TO THE SAME DIRECTOR, THE CHANGE IS REPORTED ON LINE 5 OF PART IX. NORTHERN COCHISE HOSPITAL DISTRICT 901 REX ALLEN DR WILCOX AZ 85643 TO ENSURE THE OPERATION OF THE HOSPITAL WITHIN THE DISTRICT AZ 170(C)(1) N/A N/A 0 NORTHERN COCHISE COMMUNITY HOSPITAL FOUNDATION 901 REX ALLEN DR WILCOX AZ 85643 460868855 TO PERFORM FUNDRAISING ACTIVITIES TO SUPPORT THE HOSPITAL AZ 501(C)(3) 509(A)(3) N/A 0 ARIZONA HEALTH COLLABORATIVE LLC 3030 N CENTRAL AVE PHOENIX AZ 85012 471936880 COST CONTAINMENT AND SUPPLY CHAIN OPTIMIZATION AZ UNRELATED -1249 14827 0 0 0.14000 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 NORTHERN COCHISE HOSPITAL DISTRICT C 1822438 ACTUAL CASH AMOUNT TRANSFERRED NORTHERN COCHISE HOSPITAL DISTRICT K 46180 ACTUAL EXPENSE INCURRED NORTHERN COCHISE COMMUNITY HOSPITAL FOUNDATION C 113300 ACTUAL CASH AMOUNT TRANSFERRED