2017-05-11T15:56:33-05:00 2016-06-30 461497033 EKS&H LLLP 7979 E TUFTS AVENUE SUITE 400 DENVER CO 802372521 990 2015-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 9702377000 2017-05-09 1 DORI J EGGETT P00645252 3037409400 2015 2021-01-29 14:40:06Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 1273433310 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES THROUGH LEARNING, HEALING, DISCOVERY, AND THROUGH HUMAN CONNECTION. 11 9 4147 525 5191945 4439108 2220807 1749929 471312432 497070556 23773424 34325141 10670778 12353000 507977441 545498626 31381120 33530461 0 0 185330975 204165832 0 0 0 205327882 232570715 422039977 470267008 85937464 75231618 2242473093 3847835066 1327312245 2784126390 915160848 1063708676 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 430743868 33530461 497070556 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 2016, PVHC RECORDED 53,486 PATIENT DAYS, 14,840 ADMISSIONS, 260,614 OUTPATIENT VISITS, 60,604 EMERGENCY VISITS, 2,190 DELIVERIES, 4,060 INPATIENT SURGERIES, AND 5,340 OUTPATIENT SURGERIES. 430743868 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 1 0 1 0 0 0 1 1 1 1 0 0 1 217 0 1 4147 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 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 CHRISTINE CHIN BOARD CHAIR 1.00 2.00 X X 0 0 0 MIKE DELLENBACH VICE BOARD CHAIR 1.00 2.00 X X 0 0 0 DENNIS HOUSKA BOARD MEMBER 1.00 2.00 X 0 0 0 THAINE MICHIE BOARD MEMBER 1.00 2.00 X 0 0 0 CHRIS OSBORN BOARD MEMBER 1.00 2.00 X 0 0 0 JOHN MENTGEN BOARD MEMBER 1.00 2.00 X 0 0 0 JAMES SPROWELL MD BOARD MEMBER 1.00 2.00 X 0 0 0 LAURIE STEELE BOARD MEMBER 1.00 2.00 X 0 0 0 DAN STROH BOARD MEMBER 1.00 2.00 X 0 0 0 STEVE THORSON MD BOARD MEMBER 1.00 2.00 X 0 0 0 KEVIN UNGER PRESIDENT/CEO 25.00 25.00 X X 345301 345301 79576 STEPHANIE DOUGHTY CFO 25.00 25.00 X 308025 308025 65194 DR STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 40.00 X 220602 220602 55420 DONNA PODUSKA CNO 50.00 X 257040 0 36723 MARILYN SCHOCK COO 50.00 X 182196 182196 44160 RUSS WOOLLEY VP OPERATIONS END 06/16 40.00 X 96697 96697 40286 DR JOSEPH GOTTFRIED PSYCHIATRIST 40.00 X 267070 0 49654 DR JOSEPH LOPEZ CLINICAL DIRECTOR 40.00 X 267099 0 47372 DR MICHAEL RANDLE CMO 50.00 X 411707 0 57440 KENNETH WATANABE PSYCHIATRIST 40.00 X 284696 0 48966 DR JANELL WOZNIAK CLINICAL DIRECTOR 40.00 X 282905 0 43060 2923338 1152821 567851 147 0 1 0 ALLIED BARTON SECURITY 161 WASHINGTON ST 600 CONSHOHOCKEN PA 19428 SECURITY 3032564 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY RD 300 FT COLLINS CO 80528 MEDICAL 2137393 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE 300 FT COLLINS CO 80524 MEDICAL 1911675 SUMMIT PATHOLOGY 5802 WRIGHT DR LOVELAND CO 80538 MEDICAL 1397191 FORT COLLINS YOUTH CLINIC 1214 OAK PARK DR FORT COLLINS CO 80525 MEDICAL 1309995 46 673991 695460 380478 291269 1749929 NET PATIENT SVC REV 900099 512152902 512152902 PROVIDER FEE INCOME 621400 29917093 29917093 DIETARY SVC INCOME 900099 2130084 2130084 JOINT VENTURE 621400 -47240948 -47909367 668419 111425 64871 46554 497070556 13380179 13380179 945951 945951 12936840 187969 3451594 187969 9485246 0 9485246 4476972 5008274 743552489 495574 723888070 160982 19664419 334592 19999011 19999011 400812 246069 154743 154743 MISCELLANEOUS REVENUE 621400 2092561 2092561 EHR REVENUE 624100 620450 620450 2713011 545498626 496938510 5191945 41618242 33530461 33530461 1502097 286416 1215681 64490 64490 156207183 142063848 14143335 26176819 23628549 2548270 18173070 16403952 1769118 2042173 1843371 198802 74683 74683 90062 90062 17882 17882 1489562 1489562 33099938 32240055 859883 2938408 19668 2918740 4319179 3929557 389622 6945434 6187393 758041 6561629 5823934 737695 934718 723509 211209 645178 516616 128562 6822447 6822447 23802996 18563796 5239200 2211737 128697 2083040 UBI TAXES 1592672 1592672 MEDICAL SUPPLIES 92961479 92934920 26559 PROVIDER FEE EXPENSE 22357804 22357804 BAD DEBT 18134547 18134547 7570360 4539838 3030522 470267008 430743868 39523140 0 68533778 25306411 1489346 1729412 50779998 54166356 45308 44554 6998323 8574425 3617968 5914506 628673524 333283059 254841833 295390465 780602336 909389700 26245368 26544710 1049318835 2520774527 2242473093 3847835066 63770176 84155664 59968 615274 204385503 204394246 23496487 21127201 61245 78767 1035538866 2473755238 1327312245 2784126390 X 915160848 1063708676 915160848 1063708676 2242473093 3847835066 X 75231618 -21748746 95064956 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 17882 0 0 17882 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 11242112 3051448 73951 720479 1793004 11854028 11287236 2977196 98459 1595156 1525623 11242112 10692037 4841525 985793 3756845 1455274 11287236 8938992 2680308 520466 565964 881765 10692037 8589487 1202986 379517 448977 784021 8938992 0.53810 0.46190 1 1 1 58762565 58762565 204215687 111210947 93004740 96412243 66883701 29528542 169189844 115080989 54108855 100093185 40107422 59985763 295390465 INTERCOMPANY RECEIVABLE 2489825251 DEFERRED DEBT ISSUANCE COSTS 2881259 OTHER RECEIVABLES 6819899 DEFERRED PENSION OUTFLOW COSTS 21248118 2520774527 INTERCOMPANY PAYABLES 2444166788 ACCRUED INTEREST PAYABLE 1387760 OTHER DEFERRED EXPENSES 5199882 PENSION LIABILITIES 23000808 2473755238 559205439 -21748746 3651887 -18096859 577302298 1489562 -33293234 -31803672 545498626 453788248 3651887 3651887 450136361 1489562 18641085 20130647 470267008 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 3,639,563. COGS REPORTED AS EXPENSE ON AFS 12,324. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,134,547. AUXILIARY INCOME NOT INCLUDED IN AFS INCOME 135,484. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 388,938. RENTAL EXP AS INCOME ON 990 11,046. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 46,554. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS -52,009,803. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 3,639,563. COGS REPORTED AS EXPENSE ON AFS 12,324. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,134,547. AUXILIARY GRANTS NOT ON AFS 60,000. RENTAL EXP AS INCOME ON 990 11,046. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 46,554. CASH CONTRIBUTIONS FROM FOUNDATION NOT IN AFS REVENUE 388,938. 1 1 X 1 X 250.000000000000 1 X 1 0 1 1 378787 378787 0.00080 82633124 62989688 19643436 0.04180 24183903 23036258 1147645 0.00240 107195814 86025946 21169868 0.04500 2732438 210814 2521624 0.00540 5971996 888058 5083938 0.01080 13607503 10033802 3573701 0.00760 1094779 543411 551368 0.00120 33365279 33365279 0.07090 56771995 11676085 45095910 0.09590 163967809 97702031 66265778 0.14090 146005 146005 0.00030 1375 1375 0.00000 149254 149254 0.00030 296634 296634 0.00060 1 22453818 163116547 219986824 -56870277 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 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 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: 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 ISSUE - 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 INCREASED SELF-EFFICACY TO PARTICIPANTS; COMMUNITY HEALTH WORKER MODEL PROVIDES NO-COST HEART DISEASE ASSESSMENT AND REFERRAL TO SCREENING SERVICES TO LOW-INCOME, OLDER ADULT AND/OR MINORITY POPULATIONS. HEALTH ISSUE - SUICIDE PREVENTION / SUBSTANCE ABUSE PREVENTION & TREATMENT: PLANNING TEAM FORMED TO DEVELOP METHODS TO IMPLEMENT EVIDENCE-BASED ZERO SUICIDE INITIATIVE AT BOTH HOSPITALS; 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 INCLUDED IN THE IMPLEMENTATION STRATEGY REPORT.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 62 1 - HARMONY CAMPUS MOB 2121 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICES, ONCOLOGY, HCOR, CANCER CENTER,NCPC, SSOR 2 - HARMONY CAMPUS AMBULATORY CARE CENTER 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE 3 - CHMG-LONGMONT 1925 MOUNTAIN VIEW AVE LONGMONT CO 80501 PHYSICIAN OFFICES 4 - HARMONY ED 4630 SNOW MESA DRIVE FORT COLLINS CO 80528 HARMONY ED 5 - CHMG 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 - GREELEY MEDICAL CLINIC 1900 16TH STREET GREELEY CO 80631 PHYSICIAN OFFICES, LAB, RADIOLOGY & ONCOLOGY, URGENT CARE 8 - MOUNTAIN CREST BEHAVIORAL HEALTH 4601 CORBETT DR FORT COLLINS CO 80528 BEHAVIORAL HEALTH 9 - PHYSICIAN CLINICS 4110 BRIARGATE PARKWAY COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 10 - PEAKVIEW MEDICAL CENTER 5881 W 16TH STREET GREELEY CO 80634 PHYSICIAN OFFICES, LAB & RADIOLOGY 11 - PENNOCK PLACE 1025 PENNOCK PLACE FORT COLLINS CO 80524 PHYSICIAN OFFICES, BLOOD BANK 12 - PROSPECT MEDICAL PLAZA 1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524 PHYSICIAN OFFICES, OUTPATIENT REHAB, NEUROLOGY, INT MEDICINE, RHEUMATOLOGY 13 - SNOW MESA 4674 SNOW MESA DRIVE FORT COLLINS CO 80528 PHYSICIAN OFFICES, OHS 14 - WESTBRIDGE 1107 S LEMAY FORT COLLINS CO 80524 PHYSICIAN OFFICES, BLOOD DRAW, SLEEP LAB, WEE STEPS, BRAIN & SPINE 15 - CHMG CHEYENNE MEDICAL SPECIALISTS 5050 POWDERHOUSE RD CHEYENNE WY 82009 PHYSICIAN OFFICES 16 - CENTRE AVE HEALTH AND REHAB-JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB 17 - MCR SOUTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES, HCOR, SLEEP LAB, SURGERY CENTER, NCPC 18 - MEMORIAL NEUROSCIENCES 1725 BOULDER STREET SUITE 101 COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES 19 - REDSTONE 2315 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICE, UROLOGY 20 - SURGERY CENTER OF FT COLLINS-JV 1100 E PROSPECT RD FORT COLLINS CO 80524 SURGERY CENTER 21 - WINDSOR MEDICAL CENTER 1455 MAIN STREET WINDSOR CO 80550 PHYSICIAN OFFICES, RADIOLOGY, LAB 22 - CHMG PHYSICIAN CLINICS 525 N FOOTE AVE SUITE 302 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES 23 - PHYSICIAN CLINICS 175 S UNION BLVD COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES 24 - CHMG OB-GYN CLINIC 1715 61ST AVENUE GREELEY CO 80631 PHYSICIAN OFFICES, OB-GYN 25 - CHMG-FIRESTONE 660 FIRESTONE BLVD FIRESTONE CO 80504 PHYSICIAN OFFICES NEW BUILDING WE BUILT AS OF 8/1/16 26 - UROLOGY CENTER OF THE ROCKIES 3520 E 15TH STREET LOVELAND CO 80538 PHYSICIAN OFFICES, UROLOGY 27 - WEST LOVELAND 3850 N GRANT AVE LOVELAND CO 80538 URGENT CARE, PHYSICIAN OFFICES 28 - CHILDREN'S THERAPY 1500 S LEMAY FORT COLLINS CO 80526 THERAPY 29 - CHMG PRIMARY CARE AT BRIARGATE 8890 N UNION BLVD SUITE 100B COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 30 - NORTH SPRINGS FAMILY MEDICINE & URGENT C 8540 SCARBOROUGH DRIVE COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES 31 - TIMBERLINE MEDICAL 131 STANLEY DR ESTES PARK CO 80517 PHYSICIAN OFFICES 32 - EXPRESS LAB 1020 DOCTORS LANE FORT COLLINS CO 80524 LAB TORN DOWN MOVED TO 1025 GARFIELD 33 - EXPRESS LAB 1025 GARFIELD FORT COLLINS CO 80524 EXPRESS LAB 34 - CHMG PRIMARY CARE - ROCKRIMMON 6615 DELMONICO DRIVE COLORADO SPRINGS CO 80919 PHYSICIAN OFFICES 35 - COLUMBINE POUDRE HOMECARE-JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE 36 - HCORSCOTTSBLUFF 2 W 42ND ST 2200 SCOTTSBLUFF NE 69361 PHYSICIAN OFFICES 37 - ORTHOPEDIC & HAND 3830 N GRANT AVE LOVELAND CO 80538 PHYSICIAN OFFICES 38 - MEMORIAL SUNFLOWER FAMILY MEDICINE 1730 N CORONA STREET COLORADO SPRINGS CO 80907 PHYSICIAN OFFICES 39 - PRIMARY CARE-STERLING 620 IRIS DRIVE STERLING CO 80751 PHYSICIAN OFFICES 40 - WALK IN CLINIC 2211 S COLLEGE AVE FORT COLLINS CO 80525 WALK IN CLINIC 41 - THOMPSON VALLEY TOWNE CENTER 1327 EAGLE DRIVE LOVELAND CO 80537 PHYSICIAN OFFICES 42 - THE VEIN AND LASER CENTER-JV 2008 CARIBOU DRIVE FORT COLLINS CO 80525 PHYSICIAN OFFICES 43 - WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 OUTPATIENT REHAB, CLINICAL EDUCATION 44 - CARDIOLOGY 214 S 4TH STREET KREMMLING CO 80459 PHYSICIAN OFFICES 45 - FORT MORGAN 1000 LINCOLN STREET 207 FORT MORGAN CO 80701 PHYSICIAN OFFICES 46 - EYE LASER CENTER OF N COLORADO-JV 1725 EAST PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES 47 - LARAMIE 3116 WILLET DRIVE LARAMIE WY 82070 PHYSICIAN OFFICES 48 - YAMPA VALLEY STEAMBOAT 940 CENTRAL PARK DR 290 STEAMBOAT SPRINGS CO 80487 PHYSICIAN OFFICES 49 - ESTES PARK 555 PROSPECT AVE ESTES PARK CO 80517 PHYSICIAN OFFICES 50 - SIDNEY 1625 DORWART DRIVE SIDNEY NE 69162 PHYSICIAN OFFICES 51 - CARDIOLOGY 1313 S STREET BRIDGEPORT NE 69336 PHYSICIAN OFFICES 52 - CHMG HCOR CV SURGEON 2030 MOUNTAIN VIEW AVE 540 LONGMONT CO 80501 PHYSICIAN OFFICES 53 - CHMG PRIMARY CARE - FRONT RANGE 5265 N ACADEMY BLVD SUITE 1800 COLORADO SPRINGS CO 80918 PHYSICIAN OFFICES 54 - PHLEBOTOMY STATION 1107 SOUTH LEMAY AVE FORT COLLINS CO 80526 LAB DRAWS 55 - PHLEBOTOMY STATION 1113 OAKRIDGE DRIVE FORT COLLINS CO 80525 LAB DRAWS 56 - PHLEBOTOMY STATION 2001 S SHIELDS FORT COLLINS CO 80526 LAB DRAWS 57 - PHLEBOTOMY STATION 2025 BIG HORN DRIVE FORT COLLINS CO 80525 LAB DRAWS 58 - PHLEBOTOMY STATION 3519 RICHMOND DRIVE FORT COLLINS CO 80526 LAB DRAWS 59 - HAYTHORN BROTHERS 7251 W 20TH ST GREELEY CO 80631 SLEEP LAB - VACANT 60 - CRAIG 595 RUSSELL STREET CRAIG CO 81625 PHYSICIAN OFFICES 61 - RANGEVIEW 2695 ROCKY MOUNTAIN AVE 200 LOVELAND CO 80538 NEUROLOGY 62 - PRIMARY CARE-MONUMENT 15854 JACKSON CREEK PARKWAY 120 MONUMENT CO 80132 PHYSICIAN OFFICES 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 = $22,453,818 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: 94,285,135CENTER AVE COST REPORT: 3,687,656COLUMBINE HOMECARE COST REPORT: 1,245,072PVHC DISALLOWED PROGRAMS: 802,058JOINT VENTURES: 63,096,626TOTAL TO LINE 5: 163,116,547PART 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: 116,227,937CENTRE AVE COST REPORT: 5,947,833COLUMBINE HOMECARE COST REPORT: 1,594,219PVHC DISALLOWED PROGRAMS: 1,085,373JOINT VENTURES: 95,131,462TOTAL TO LINE 6: 219,986,824 PART III, LINE 8: APPROXIMATELY 25% 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 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 PATHWAYS HOSPICE 305 CARPENTER ROAD FORT COLLINS CO 80525 840782874 501(C )(3) 6300 SEE SCH I, PART IV DOWNTOWN BUSINESS ASSOCIATION 19 OLD TOWN SQUARE 230 FORT COLLINS CO 80524 840535419 501(C )(3) 30000 SEE SCH I, PART IV GREELEY CENTENNIAL ROTARY 1035 37TH AVE CT GREELEY CO 80634 840714073 501(C )(3) 7500 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 N 30TH STREET LARAMIE WY 82072 836000188 501(C )(3) 8300 SEE SCH I, PART IV NORTH RANGE BEHAVIORAL HEALTH 1300 N 17TH STREET GREELEY CO 80631 840622660 501(C )(3) 5225 SEE SCH I, PART IV POUDRE VALLEY MEDICAL GROUP 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 800348943 N/A 26399329 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 17TH PLACE AURORA CO 80045 846000555 501(C )(3) 5895235 SEE SCH I, PART IV SUMMITSTONE HEALTH PARTNERS 525 W OAK ST FORT COLLINS CO 80521 841512383 501(C )(3) 7000 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE ST 102 FORT COLLINS CO 80524 846031503 501(C )(3) 55674 SEE SCH I, PART IV UNIVERSITY OF N COLORADO 501 20TH STREET GREELEY CO 80639 846000546 GOVERNMENT 58333 SEE SCH I, PART IV NORTHERN COLORADO UNITED FOR YOU 2015 CLUBHOUSE 203 GREELEY CO 80634 208575428 501(C )(3) 13400 SEE SCH I, PART IV PVH FOUNDATION 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 883163 SEE SCH I, PART IV PROJECT SELF SUFFICIENCY 375 W 37TH STREET LOVELAND CO 80538 841206341 501(C )(3) 6325 SEE SCH I, PART IV BOYS AND GIRLS CLUB OF LARIMER 103 SMOKEY STREET FORT COLLINS CO 80525 742425914 501(C )(3) 6950 SEE SCH I, PART IV CO NONPROFIT DEVELOPMENT CENTER 789 SHERMAN ST SUITE 250 DENVER CO 80203 841493585 501(C )(3) 20000 SEE SCH I, PART IV FOOD BANK OF LARIMER COUNTY 1301 BLUE SPRUCE DRIVE FORT COLLINS CO 80524 742336171 501(C )(3) 9800 SEE SCH I, PART IV 15 1 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 X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KEVIN UNGER PRESIDENT/CEO 233150 233150 105342 105342 6809 6809 3975 3975 35813 35813 385089 385089 0 0 STEPHANIE DOUGHTY CFO 239935 239935 65734 65734 2356 2356 3975 3975 28622 28622 340622 340622 0 0 DR STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 172739 172739 45296 45296 2567 2567 3975 3975 23735 23735 248312 248312 0 0 DONNA PODUSKA CNO 200034 0 51663 0 5343 0 7534 0 29189 0 293763 0 0 0 MARILYN SCHOCK COO 149070 149070 32365 32365 761 761 3751 3751 18329 18329 204276 204276 0 0 RUSS WOOLLEY VP OPERATIONS END 06/16 76307 76307 20264 20264 126 126 2943 2943 17200 17200 116840 116840 0 0 DR JOSEPH GOTTFRIED PSYCHIATRIST 260421 0 6121 0 528 0 7950 0 41704 0 316724 0 0 0 DR JOSEPH LOPEZ CLINICAL DIRECTOR 265710 0 0 0 1389 0 7950 0 39422 0 314471 0 0 0 DR MICHAEL RANDLE CMO 325527 0 83050 0 3130 0 7950 0 49490 0 469147 0 0 0 KENNETH WATANABE PSYCHIATRIST 256530 0 27778 0 388 0 7950 0 41016 0 333662 0 0 0 DR JANELL WOZNIAK CLINICAL DIRECTOR 255754 0 26887 0 264 0 5318 0 37742 0 325965 0 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS: PER SYSTEM POLICY, TRAVEL FOR COMPANIONS IS NOT REIMBURSABLE. FOR CONVENIENCE OF TRAVEL ARRANGEMENTS FOR THE ANNUAL BOARD MEMBER RETREAT AND SELECT CONFERENCES, PVHC PAYS FOR ONE COMPANION PER BOARD MEMBER AND EMPLOYEE ATTENDING THE CONFERENCE. EACH BOARD MEMBER RECEIVES A FORM 1099 FOR THIS INCOME. EACH EMPLOYEE HAS THIS ADDED TO THEIR FORM W-2. 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. 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 26294807 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2015 SERIES A 841179794 914183AV0 2015-02-04 71125100 CONSTRUCTION COSTS AT PVH 0 0 0 D UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2015 SERIES C 841179794 914183AX6 2015-02-04 56850000 REFUNDING 2005F BONDS 0 0 0 A 50000000 4021772 433893 1340216 44204119 2005 0 1 1 1 B 26294807 2115034 397052 2024595 21758126 2005 1 0 1 1 C 71125100 18023097 590936 31219881 21291186 2016 0 0 0 1 D 56850000 472333 56377667 2015 0 1 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 1 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 8038: $83,000,000. SCHEDULE K, PART IV, LINE 2C THE REBATE CALCULATION WAS PERFORMED IN APRIL 2015 FOR BOND ISSUANCES A AND B. KATHLEEN MICHIE SEE PART V 64490 SEE PART V 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS (A) NAME OF PERSON: KATHLEEN MICHIE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: KATHLEEN MICHIE IS A FAMILY MEMBER OF THAINE MICHIE, DIRECTOR(D) DESCRIPTION OF TRANSACTION: W-2 WAGES X MEDICAL EQUIPMENT 36 285053 FMV 0 0 0 FORM 990, PART I, LINE 6 PVH HAS 525 ACTIVE VOLUNTEERS IN FISCAL YEAR 2016. 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 UCHEALTH NORTHERN REGION TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11 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 43,130,637. AUXILIARY INCOME ON 990, NOT IN AUDIT -135,484. DONATION TO FOUNDATION FROM AUXILIARY NOT IN AUDIT EXPENSE 60,000. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 52,009,803. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO 3921 -16785 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 6140871 23024679 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 21034 657338 PVHC INC UNITED MED ALLIANCE 2021 BATTLECREEK DRIVE STE A FORT COLLINS CO 80528 820572743 HEALTH CLAIMS CO -149508 0 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 2381451 2805265 0 0 0.50000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED -343986 539407 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 312508 743856 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 42819 77198 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FORT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 5037484 12784181 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED 186442 1109784 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 10944 29976 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 441021 2085210 0 0 0.46000 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 584763 1126468 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 -51344192 32537180 0 1 0.99000 PVHS-ICM EHW 3702 AUTOMATION WAY 103 FORT COLLINS CO 80525 463311308 MEDICAL SERVICES CO N/A RELATED 121392 251113 0 0 0.50000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A UNRELATED 120158 57372 0 0 0.14290 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO PVHC C 842084 1510052 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 925447 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 634519 TRANSACTION TOTAL HARMONY SURGERY CENTER S 1950000 TRANSACTION TOTAL HARMONY SURGERY CENTER M 51226 TRANSACTION TOTAL CENTRE AVE HEALTH & REHAB B 350000 TRANSACTION TOTAL COLUMBINE POUDRE HOMECARE S 200000 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 213621 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 5995843 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 6733013 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 6816085 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES S 43130660 TRANSACTION TOTAL PVHMCR FOUNDATION B 881164 TRANSACTION TOTAL PVHMCR FOUNDATION C 673991 TRANSACTION TOTAL PVHMCR FOUNDATION H 114900 TRANSACTION TOTAL PVHMCR FOUNDATION L 54440 TRANSACTION TOTAL PVHMCR FOUNDATION N 70779 TRANSACTION TOTAL INNOVATION ENTERPRISES A 119031 TRANSACTION TOTAL INNOVATION ENTERPRISES A 244017 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 26399329 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC H 163759 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 1766407 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 3715636 TRANSACTION TOTAL UCHEALTH HOME MEDICAL SUPPLY S 248709 TRANSACTION TOTAL PVHS-ICM S 68000 TRANSACTION TOTAL