STRATEGY STUDIO / NONPROFIT PEOPLE SEARCH

CULBERTSON FROID BAINVILLE HEALTH CARE CORPORATION: Form 990, tax year 2015

View the entire original 990 at ProPublica ↗

Organization
CULBERTSON FROID BAINVILLE HEALTH CARE CORPORATION (EIN 81-0373589)
Tax period
2015-05-01 to 2016-04-30
Filed
2017-03-14
IRS object ID
201720739349300642
Schema version
2015v3.0
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2017-03-14T11:34:35-06:00ReturnTs
Tax Period End2016-04-30TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1GREEN HEALTH GROUP PCBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line1110 5TH ST S SUITE 106AddressLine1Txt
CityGLASGOWCityNm
State AbbreviationMTStateAbbreviationCd
ZIP592302338ZIPCd
FieldValueIRS element (for citing)
Return Type990ReturnTypeCd
Tax Period Begin2015-05-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN810373589EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1CULBERTSON FROID BAINVILLEBusinessNameLine1Txt
Business Name Line2HEALTHCARE CORPORATIONBusinessNameLine2Txt
FieldValueIRS element (for citing)
Business Name ControlCULBBusinessNameControlTxt
Phone4067876401PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 419AddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonAUDREY STROMBERGPersonNm
Person TitleADMINISTRATORPersonTitleTxt
Phone4067876401PhoneNum
Signature2017-03-10SignatureDt
Discuss With Paid PreparerYes (true)DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonDANIEL GREENPreparerPersonNm
PTINP01311679PTIN
Phone4062632615PhoneNum
Preparation2017-03-14PreparationDt
FieldValueIRS element (for citing)
Tax2015TaxYr
Build TS2021-01-29 14:40:06ZBuildTS

Form 990 IRS990

Doing Business As Name DoingBusinessAsName

FieldValueIRS element (for citing)
Business Name Line1ROOSEVELT MEDICAL CENTERBusinessNameLine1Txt
FieldValueIRS element (for citing)
Principal OfficerAUDREY STROMBERGPrincipalOfficerNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 419AddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd
FieldValueIRS element (for citing)
Gross Receipts$5,450,233GrossReceiptsAmt
Group Return For AffiliatesfalseGroupReturnForAffiliatesInd
Organization501c3Yes (X)Organization501c3Ind
Website AddressROOSEVELTMEDICAL.ORGWebsiteAddressTxt
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Formation1976FormationYr
Legal Domicile StateMTLegalDomicileStateCd
Activity Or MissionROOSEVELT MEDICAL CENTER IS DEDICATED TO PROVIDING PATIENTS WITH APPROPRIATE, PERSONALIZED, AND QUALITY HEALTH CARE.ActivityOrMissionDesc
Voting Members Governing Body9VotingMembersGoverningBodyCnt
Voting Members Independent9VotingMembersIndependentCnt
Total Employee120TotalEmployeeCnt
Total Volunteers50TotalVolunteersCnt
Total Gross UBI$0TotalGrossUBIAmt
PY Contributions Grants$151,662PYContributionsGrantsAmt
CY Contributions Grants$265,035CYContributionsGrantsAmt
PY Program Service Revenue$4,960,228PYProgramServiceRevenueAmt
CY Program Service Revenue$4,928,374CYProgramServiceRevenueAmt
PY Investment Income$1,766PYInvestmentIncomeAmt
CY Investment Income$1,663CYInvestmentIncomeAmt
PY Other Revenue$290,982PYOtherRevenueAmt
CY Other Revenue$255,161CYOtherRevenueAmt
PY Total Revenue$5,404,638PYTotalRevenueAmt
CY Total Revenue$5,450,233CYTotalRevenueAmt
CY Grants And Similar Paid$0CYGrantsAndSimilarPaidAmt
CY Benefits Paid To Members$0CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid$3,416,098PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid$3,507,263CYSalariesCompEmpBnftPaidAmt
CY Total Prof Fndrsng Expns$0CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense$30,604CYTotalFundraisingExpenseAmt
PY Other Expenses$2,088,536PYOtherExpensesAmt
CY Other Expenses$2,098,397CYOtherExpensesAmt
PY Total Expenses$5,504,634PYTotalExpensesAmt
CY Total Expenses$5,605,660CYTotalExpensesAmt
PY Revenues Less Expenses-$99,996PYRevenuesLessExpensesAmt
CY Revenues Less Expenses-$155,427CYRevenuesLessExpensesAmt
Total Assets BOY$2,813,273TotalAssetsBOYAmt
Total Assets EOY$2,576,159TotalAssetsEOYAmt
Total Liabilities BOY$904,057TotalLiabilitiesBOYAmt
Total Liabilities EOY$822,370TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY$1,909,216NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY$1,753,789NetAssetsOrFundBalancesEOYAmt
MissionROOSEVELT MEDICAL CENTER IS DEDICATED TO PROVIDING PATIENTS WITH APPROPRIATE, PERSONALIZED, AND QUALITY HEALTH CARE.MissionDesc
Significant New Program SrvcfalseSignificantNewProgramSrvcInd
Significant ChangefalseSignificantChangeInd
Expense$4,099,369ExpenseAmt
Revenue$4,928,374RevenueAmt
DescROOSEVELT MEDICAL CENTER IS DEDICATED TO PROVIDING PATIENTS WITH APPROPRIATE, PERSONALIZED, AND QUALITY HEALTH CARE.Desc
Total Program Service Expenses$4,099,369TotalProgramServiceExpensesAmt
Described In Section501c3Yes (true)DescribedInSection501c3Ind
Schedule B RequiredYes (true)ScheduleBRequiredInd
Political Campaign ActyfalsePoliticalCampaignActyInd
Lobbying ActivitiesYes (true)LobbyingActivitiesInd
Subject To Proxy TaxfalseSubjectToProxyTaxInd
Donor Advised FundfalseDonorAdvisedFundInd
Conservation EasementsfalseConservationEasementsInd
Collections Of ArtfalseCollectionsOfArtInd
Credit CounselingfalseCreditCounselingInd
Temp Or Permanent EndowmentsfalseTempOrPermanentEndowmentsInd
Report Land Building EquipmentYes (true)ReportLandBuildingEquipmentInd
Report Investments Other SecfalseReportInvestmentsOtherSecInd
Report Program Related InvstfalseReportProgramRelatedInvstInd
Report Other AssetsfalseReportOtherAssetsInd
Report Other LiabilitiesYes (true)ReportOtherLiabilitiesInd
Include FIN48 FootnoteYes (true)IncludeFIN48FootnoteInd
Independent Audit Fincl StmtfalseIndependentAuditFinclStmtInd
Consolidated Audit Fincl StmtYes (true)ConsolidatedAuditFinclStmtInd
School OperatingfalseSchoolOperatingInd
Foreign OfficefalseForeignOfficeInd
Foreign ActivitiesfalseForeignActivitiesInd
More Than5000 K To OrgfalseMoreThan5000KToOrgInd
More Than5000 K To IndividualsfalseMoreThan5000KToIndividualsInd
Professional FundraisingfalseProfessionalFundraisingInd
Fundraising ActivitiesfalseFundraisingActivitiesInd
Gaming ActivitiesfalseGamingActivitiesInd
Operate HospitalYes (true)OperateHospitalInd
Audited Financial Stmt AttYes (true)AuditedFinancialStmtAttInd
Grants To OrganizationsfalseGrantsToOrganizationsInd
Grants To IndividualsfalseGrantsToIndividualsInd
Schedule J RequiredYes (true)ScheduleJRequiredInd
Tax Exempt BondsfalseTaxExemptBondsInd
Engaged In Excess Benefit TransfalseEngagedInExcessBenefitTransInd
PY Excess Benefit TransfalsePYExcessBenefitTransInd
Loan OutstandingfalseLoanOutstandingInd
Grant To Related PersonfalseGrantToRelatedPersonInd
Business Rln With Org MemfalseBusinessRlnWithOrgMemInd
Business Rln With Fam MemfalseBusinessRlnWithFamMemInd
Business Rln With Officer EntfalseBusinessRlnWithOfficerEntInd
Deductible Non Cash ContriYes (true)DeductibleNonCashContriInd
Deductible Art ContributionfalseDeductibleArtContributionInd
Terminate OperationsfalseTerminateOperationsInd
Partial LiquidationfalsePartialLiquidationInd
Disregarded EntityfalseDisregardedEntityInd
Related EntityYes (true)RelatedEntityInd
Related Organization Ctrl EntfalseRelatedOrganizationCtrlEntInd
Trnsfr Exmpt Non Chrtbl Rltd OrgfalseTrnsfrExmptNonChrtblRltdOrgInd
Activities Conducted PrtshpfalseActivitiesConductedPrtshpInd
Schedule O RequiredYes (true)ScheduleORequiredInd
IRP Document12IRPDocumentCnt
IRP Document W2 G0IRPDocumentW2GCnt
Employee120EmployeeCnt
Employment Tax Returns FiledYes (true)EmploymentTaxReturnsFiledInd
Unrelated Bus Incm Over LimitfalseUnrelatedBusIncmOverLimitInd
Foreign Financial AccountfalseForeignFinancialAccountInd
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTransInd
Taxable Party NotificationfalseTaxablePartyNotificationInd
Nondeductible ContributionsfalseNondeductibleContributionsInd
Indoor Tanning ServicesfalseIndoorTanningServicesInd
Info In Schedule O Part VIYes (X)InfoInScheduleOPartVIInd
Governing Body Voting Members9GoverningBodyVotingMembersCnt
Independent Voting Member9IndependentVotingMemberCnt
Family Or Business RlnYes (true)FamilyOrBusinessRlnInd
Delegation Of Mgmt DutiesfalseDelegationOfMgmtDutiesInd
Change To Org DocumentsfalseChangeToOrgDocumentsInd
Material Diversion Or MisusefalseMaterialDiversionOrMisuseInd
Members Or StockholdersfalseMembersOrStockholdersInd
Election Of Board MembersfalseElectionOfBoardMembersInd
Decisions Subject To ApprovafalseDecisionsSubjectToApprovaInd
Minutes Of Governing BodyYes (true)MinutesOfGoverningBodyInd
Minutes Of CommitteesYes (true)MinutesOfCommitteesInd
Officer Mailing AddressfalseOfficerMailingAddressInd
Local ChaptersfalseLocalChaptersInd
Form990 Provided To Gvrn BodyYes (true)Form990ProvidedToGvrnBodyInd
Conflict Of Interest PolicyYes (true)ConflictOfInterestPolicyInd
Annual Disclosure Covered PrsnYes (true)AnnualDisclosureCoveredPrsnInd
Regular Monitoring EnfrcYes (true)RegularMonitoringEnfrcInd
Whistleblower PolicyYes (true)WhistleblowerPolicyInd
Document Retention PolicyYes (true)DocumentRetentionPolicyInd
Compensation Process CEOYes (true)CompensationProcessCEOInd
Compensation Process OtherYes (true)CompensationProcessOtherInd
Investment In Joint VenturefalseInvestmentInJointVentureInd
Upon RequestYes (X)UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

FieldValueIRS element (for citing)
PersonJENNIFER KESSNERPersonNm
Phone4067876401PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 419AddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd

Form990 Part VII Section A Form990PartVIISectionAGrp (13 entries)

TitleTitleTxtAverage Hours Per WeekAverageHoursPerWeekRtIndividual Trustee Or DirectorIndividualTrusteeOrDirectorIndReportable Comp From OrgReportableCompFromOrgAmtReportable Comp From Rltd OrgReportableCompFromRltdOrgAmtOther CompensationOtherCompensationAmtAverage Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRtOfficerOfficerIndHighest Compensated EmployeeHighestCompensatedEmployeeInd
PAULA SCHLEDEWITZ
CHAIR1.00Yes (X)$0$0$0
LANA ENGELKE
DIRECTOR1.00Yes (X)$0$0$0
MARK COLVIN
DIRECTOR1.00Yes (X)$0$0$0
GRANT SALVEVOLD
DIRECTOR1.00Yes (X)$0$0$0
BOB BEERY
DIRECTOR1.00Yes (X)$0$0$0
DUANE LARSEN
DIRECTOR1.00Yes (X)$0$0$0
KEVIN MILLER
DIRECTOR1.00Yes (X)$0$0$0
SHARON SCHMITZ
DIRECTOR1.00Yes (X)$0$0$0
JO NELSON
DIRECTOR1.00Yes (X)$0$0$0
AUDREY STROMBERG
ADMINISTRATO40.00$91,137$0$50.00Yes (X)
JENNIFER KESSNER
CFO42.00$87,157$0$305Yes (X)
DON HELLAND
MD40.00$197,586$0$5,201Yes (X)
ELIZABETH KLEPPEN
PA-C21.00$163,684$0$305Yes (X)
FieldValueIRS element (for citing)
Total Reportable Comp From Org$539,564TotalReportableCompFromOrgAmt
Total Other Compensation$5,816TotalOtherCompensationAmt
Indiv Rcvd Greater Than100 K2IndivRcvdGreaterThan100KCnt
Former Ofcr Employees ListedfalseFormerOfcrEmployeesListedInd
Total Comp Greater Than150 KYes (true)TotalCompGreaterThan150KInd
Compensation From Other SrcsfalseCompensationFromOtherSrcsInd

Contractor Compensation ContractorCompensationGrp (3 entries)

Address Line1ContractorAddress/USAddress/AddressLine1TxtCityContractorAddress/USAddress/CityNmState AbbreviationContractorAddress/USAddress/StateAbbreviationCdZIPContractorAddress/USAddress/ZIPCdServicesServicesDescCompensationCompensationAmt
MONTANA HEALTH NETWORK
11 SOUTH 7TH STREET SUITE 241MILES CITYMT59301LOCUM NURSE, PA$316,909
HEALTHCARE SERVICES GROUP INC
3220 TILLMAN DRIVE SUITE 300BENSALEMPA19020DIETARY SVC$206,513
AUREUS RADIOLOGY LLC
BOX 3037OMAHANE681030037LOCUM LAB STAFF$102,350
FieldValueIRS element (for citing)
Cntrct Rcvd Greater Than100 K3CntrctRcvdGreaterThan100KCnt
Related Organizations$62,247RelatedOrganizationsAmt
Government Grants$59,639GovernmentGrantsAmt
All Other Contributions$143,149AllOtherContributionsAmt
Noncash Contributions$44,000NoncashContributionsAmt
Total Contributions$265,035TotalContributionsAmt

Program Service Revenue ProgramServiceRevenueGrp (2 entries)

DescDescBusinessBusinessCdTotal Revenue ColumnTotalRevenueColumnAmtRelated Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt
PATIENT REVENUE621500$4,871,798$4,871,798
MISC REVENUE900099$56,576$56,576
FieldValueIRS element (for citing)
Total Program Service Revenue$4,928,374TotalProgramServiceRevenueAmt

Investment Income InvestmentIncomeGrp

FieldValueIRS element (for citing)
Total Revenue Column$1,663TotalRevenueColumnAmt
Related Or Exempt Func Income$1,663RelatedOrExemptFuncIncomeAmt

Other Revenue Misc OtherRevenueMiscGrp

FieldValueIRS element (for citing)
DescHOSPITAL DISTRICT SUBSIDYDesc
Business900099BusinessCd
Total Revenue Column$255,161TotalRevenueColumnAmt
Related Or Exempt Func Income$255,161RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Other Revenue Total$255,161OtherRevenueTotalAmt

Total Revenue TotalRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$5,450,233TotalRevenueColumnAmt
Related Or Exempt Func Income$5,185,198RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Info In Schedule O Part IXYes (X)InfoInScheduleOPartIXInd

Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp

FieldValueIRS element (for citing)
Total$182,545TotalAmt
Management And General$182,545ManagementAndGeneralAmt

Other Salaries And Wages OtherSalariesAndWagesGrp

FieldValueIRS element (for citing)
Total$2,900,447TotalAmt
Program Services$2,470,659ProgramServicesAmt
Management And General$402,915ManagementAndGeneralAmt
Fundraising$26,873FundraisingAmt

Pension Plan Contributions PensionPlanContributionsGrp

FieldValueIRS element (for citing)
Total$16,487TotalAmt
Program Services$13,212ProgramServicesAmt
Management And General$3,131ManagementAndGeneralAmt
Fundraising$144FundraisingAmt

Other Employee Benefits OtherEmployeeBenefitsGrp

FieldValueIRS element (for citing)
Total$143,386TotalAmt
Program Services$110,029ProgramServicesAmt
Management And General$32,171ManagementAndGeneralAmt
Fundraising$1,186FundraisingAmt

Payroll Taxes PayrollTaxesGrp

FieldValueIRS element (for citing)
Total$264,398TotalAmt
Program Services$206,120ProgramServicesAmt
Management And General$55,877ManagementAndGeneralAmt
Fundraising$2,401FundraisingAmt

Fees For Services Other FeesForServicesOtherGrp

FieldValueIRS element (for citing)
Total$908,353TotalAmt
Program Services$865,334ProgramServicesAmt
Management And General$43,019ManagementAndGeneralAmt

Advertising AdvertisingGrp

FieldValueIRS element (for citing)
Total$32,431TotalAmt
Management And General$32,431ManagementAndGeneralAmt

Office Expenses OfficeExpensesGrp

FieldValueIRS element (for citing)
Total$235,705TotalAmt
Program Services$37,749ProgramServicesAmt
Management And General$197,956ManagementAndGeneralAmt

Information Technology InformationTechnologyGrp

FieldValueIRS element (for citing)
Total$2,160TotalAmt
Management And General$2,160ManagementAndGeneralAmt

Travel TravelGrp

FieldValueIRS element (for citing)
Total$1,839TotalAmt
Program Services$1,839ProgramServicesAmt

Conferences Meetings ConferencesMeetingsGrp

FieldValueIRS element (for citing)
Total$50,088TotalAmt
Program Services$33,331ProgramServicesAmt
Management And General$16,757ManagementAndGeneralAmt

Interest InterestGrp

FieldValueIRS element (for citing)
Total$1,449TotalAmt
Program Services$2ProgramServicesAmt
Management And General$1,447ManagementAndGeneralAmt

Depreciation Depletion DepreciationDepletionGrp

FieldValueIRS element (for citing)
Total$264,131TotalAmt
Management And General$264,131ManagementAndGeneralAmt

Insurance InsuranceGrp

FieldValueIRS element (for citing)
Total$106,558TotalAmt
Management And General$106,558ManagementAndGeneralAmt

Other Expenses OtherExpensesGrp (4 entries)

DescDescTotalTotalAmtProgram ServicesProgramServicesAmtManagement And GeneralManagementAndGeneralAmt
MEDICAL SUPPLIES$255,657$255,657
REPAIRS & MAINTENANCE$197,563$64,284$133,279
MISC$26,333$26,333
FOOD & DIETARY SUPPLIES$13,070$13,070

All Other Expenses AllOtherExpensesGrp

FieldValueIRS element (for citing)
Total$3,060TotalAmt
Program Services$1,750ProgramServicesAmt
Management And General$1,310ManagementAndGeneralAmt

Total Functional Expenses TotalFunctionalExpensesGrp

FieldValueIRS element (for citing)
Total$5,605,660TotalAmt
Program Services$4,099,369ProgramServicesAmt
Management And General$1,475,687ManagementAndGeneralAmt
Fundraising$30,604FundraisingAmt

Cash Non Interest Bearing CashNonInterestBearingGrp

FieldValueIRS element (for citing)
BOY$2,838BOYAmt
EOY$2,702EOYAmt

Savings And Temp Cash Invst SavingsAndTempCashInvstGrp

FieldValueIRS element (for citing)
BOY$999,720BOYAmt
EOY$843,497EOYAmt

Pledges And Grants Receivable PledgesAndGrantsReceivableGrp

FieldValueIRS element (for citing)
BOY$116,327BOYAmt
EOY$92,488EOYAmt

Accounts Receivable AccountsReceivableGrp

FieldValueIRS element (for citing)
BOY$718,074BOYAmt
EOY$722,344EOYAmt

Inventories For Sale Or Use InventoriesForSaleOrUseGrp

FieldValueIRS element (for citing)
BOY$111,568BOYAmt
EOY$118,226EOYAmt

Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp

FieldValueIRS element (for citing)
BOY$62,939BOYAmt
EOY$61,261EOYAmt
FieldValueIRS element (for citing)
Land Bldg Equip Cost Or Other Bss$5,339,772LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec$4,669,131LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

FieldValueIRS element (for citing)
BOY$736,807BOYAmt
EOY$670,641EOYAmt

Other Assets Total OtherAssetsTotalGrp

FieldValueIRS element (for citing)
BOY$65,000BOYAmt
EOY$65,000EOYAmt

Total Assets TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$2,813,273BOYAmt
EOY$2,576,159EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

FieldValueIRS element (for citing)
BOY$550,980BOYAmt
EOY$486,062EOYAmt

Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp

FieldValueIRS element (for citing)
BOY$245,396BOYAmt
EOY$202,691EOYAmt

Other Liabilities OtherLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$107,681BOYAmt
EOY$133,617EOYAmt

Total Liabilities TotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$904,057BOYAmt
EOY$822,370EOYAmt
FieldValueIRS element (for citing)
Organization Follows SFAS117Yes (X)OrganizationFollowsSFAS117Ind

Unrestricted Net Assets UnrestrictedNetAssetsGrp

FieldValueIRS element (for citing)
BOY$1,862,861BOYAmt
EOY$1,719,176EOYAmt

Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp

FieldValueIRS element (for citing)
BOY$46,355BOYAmt
EOY$34,613EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,909,216BOYAmt
EOY$1,753,789EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$2,813,273BOYAmt
EOY$2,576,159EOYAmt
FieldValueIRS element (for citing)
Reconcilation Revenue Expnss-$155,427ReconcilationRevenueExpnssAmt
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Accountant Compile Or ReviewfalseAccountantCompileOrReviewInd
FS AuditedYes (true)FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

FieldValueIRS element (for citing)
Consolidated Basis Fincl StmtYes (X)ConsolidatedBasisFinclStmtInd
FieldValueIRS element (for citing)
Audit CommitteeYes (true)AuditCommitteeInd
Federal Grant Audit RequiredfalseFederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
HospitalYes (X)HospitalInd

Schedule B IRS990ScheduleB

Contributor Information ContributorInformationGrp

FieldValueIRS element (for citing)
ContributorRESTRICTEDContributorNum

Contributor Business Name ContributorBusinessName

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor US Address ContributorUSAddress

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Total ContributionsRESTRICTEDTotalContributionsAmt

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
VolunteersfalseVolunteersInd
Paid Staff Or ManagementfalsePaidStaffOrManagementInd
Media AdvertisementsfalseMediaAdvertisementsInd
Mailings MembersfalseMailingsMembersInd
Publications Or BroadcastfalsePublicationsOrBroadcastInd
Grants Other OrganizationsfalseGrantsOtherOrganizationsInd
Direct Contact LegislatorsfalseDirectContactLegislatorsInd
Rallies DemonstrationsfalseRalliesDemonstrationsInd
Other ActivitiesYes (true)OtherActivitiesInd
Other Activities$374OtherActivitiesAmt
Total Lobbying Expenditures$374TotalLobbyingExpendituresAmt
Not Described Section501c3falseNotDescribedSection501c3Ind

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE C, PART IVFormAndLineReferenceDesc
Explanation2.44 PERCENT OF DUES PAID TO MHA AND 22.12 PERCENT OF DUES PAID TO AHA, WHICH TOTALED 374, WERE USED FOR LOBBYING EXPENSES BY MHA.ExplanationTxt

Schedule D IRS990ScheduleD

Buildings BuildingsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$3,028,111OtherCostOrOtherBasisAmt
Depreciation$2,803,653DepreciationAmt
Book Value$224,458BookValueAmt

Equipment EquipmentGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$2,311,661OtherCostOrOtherBasisAmt
Depreciation$1,865,478DepreciationAmt
Book Value$446,183BookValueAmt
FieldValueIRS element (for citing)
Total Book Value Land Buildings$670,641TotalBookValueLandBuildingsAmt

Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)

DescDescAmtAmt
MEDICARE/MEDICAID ESTIMATED PAYABLE$88,000
RESIDENT DEPOSITS PAYABLE$45,617
FieldValueIRS element (for citing)
Total Liability$133,617TotalLiabilityAmt
Footnote TextYes (X)FootnoteTextInd
Total Rev Etc Audited Fincl Stmt$5,450,233TotalRevEtcAuditedFinclStmtAmt
Revenue Subtotal$5,450,233RevenueSubtotalAmt
Total Revenue Per Form990$5,450,233TotalRevenuePerForm990Amt
Tot Expns Etc Audited Fincl Stmt$5,605,660TotExpnsEtcAuditedFinclStmtAmt
Expenses Subtotal$5,605,660ExpensesSubtotalAmt
Total Expenses Per Form990$5,605,660TotalExpensesPerForm990Amt

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE D, PAGE 3, PART XFormAndLineReferenceDesc
ExplanationIT IS THE JUDGEMENT OF MANAGEMENT THAT THE COMPANY HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS THAT WOULD BE SUBJECT TO CHANGE UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE.ExplanationTxt

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Financial Assistance PolicyYes (true)FinancialAssistancePolicyInd
Written PolicyYes (true)WrittenPolicyInd
FPG Reference Free CareYes (true)FPGReferenceFreeCareInd
Percent100Yes (X)Percent100Ind
FPG Reference Discounted CareYes (true)FPGReferenceDiscountedCareInd
Percent200 DYes (X)Percent200DInd
Free Care Medically IndigentYes (true)FreeCareMedicallyIndigentInd
Financial Assistance BudgetYes (true)FinancialAssistanceBudgetInd
Expenses Exceed BudgetYes (true)ExpensesExceedBudgetInd
Unable To Provide CarefalseUnableToProvideCareInd
Annual Community Bnft ReportfalseAnnualCommunityBnftReportInd

Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp

FieldValueIRS element (for citing)
Total Community Benefit Expns$78,637TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$14,792DirectOffsettingRevenueAmt
Net Community Benefit Expns$63,845NetCommunityBenefitExpnsAmt
Total Expense0.01140TotalExpensePct

Unreimbursed Medicaid UnreimbursedMedicaidGrp

FieldValueIRS element (for citing)
Total Community Benefit Expns$1,126,461TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$997,706DirectOffsettingRevenueAmt
Net Community Benefit Expns$128,755NetCommunityBenefitExpnsAmt
Total Expense0.02300TotalExpensePct

Total Financial Assistance Typ TotalFinancialAssistanceTyp

FieldValueIRS element (for citing)
Total Community Benefit Expns$1,205,098TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$1,012,498DirectOffsettingRevenueAmt
Net Community Benefit Expns$192,600NetCommunityBenefitExpnsAmt
Total Expense0.03440TotalExpensePct

Community Health Services CommunityHealthServicesGrp

FieldValueIRS element (for citing)
Total Community Benefit Expns$151,805TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$17,507DirectOffsettingRevenueAmt
Net Community Benefit Expns$134,298NetCommunityBenefitExpnsAmt
Total Expense0.02400TotalExpensePct

Subsidized Health Services SubsidizedHealthServicesGrp

FieldValueIRS element (for citing)
Total Community Benefit Expns$585,203TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$414,825DirectOffsettingRevenueAmt
Net Community Benefit Expns$170,378NetCommunityBenefitExpnsAmt
Total Expense0.03040TotalExpensePct

Total Other Benefits TotalOtherBenefitsGrp

FieldValueIRS element (for citing)
Total Community Benefit Expns$737,008TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$432,332DirectOffsettingRevenueAmt
Net Community Benefit Expns$304,676NetCommunityBenefitExpnsAmt
Total Expense0.05440TotalExpensePct

Total Community Benefits TotalCommunityBenefitsGrp

FieldValueIRS element (for citing)
Total Community Benefit Expns$1,942,106TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue$1,444,830DirectOffsettingRevenueAmt
Net Community Benefit Expns$497,276NetCommunityBenefitExpnsAmt
Total Expense0.08870TotalExpensePct
FieldValueIRS element (for citing)
Bad Debt Expense ReportedYes (true)BadDebtExpenseReportedInd
Bad Debt Expense$163,118BadDebtExpenseAmt
Reimbursed By Medicare$1,927,168ReimbursedByMedicareAmt
Cost Of Care Reimbursed By Medcr$1,969,985CostOfCareReimbursedByMedcrAmt
Medicare Surplus Or Shortfall-$42,817MedicareSurplusOrShortfallAmt

Costing Methodology Used CostingMethodologyUsedGrp

FieldValueIRS element (for citing)
OtherYes (X)OtherInd
FieldValueIRS element (for citing)
Written Debt Collection PolicyYes (true)WrittenDebtCollectionPolicyInd
Financial Assistance PrvsnYes (true)FinancialAssistancePrvsnInd
Hospital Facilities1HospitalFacilitiesCnt

Hospital Facilities HospitalFacilitiesGrp

FieldValueIRS element (for citing)
Facility1FacilityNum

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1ROOSEVELT MEDICAL CENTERBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 419AddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd
FieldValueIRS element (for citing)
Licensed HospitalYes (X)LicensedHospitalInd
General Medical And SurgicalYes (X)GeneralMedicalAndSurgicalInd
Critical Access HospitalYes (X)CriticalAccessHospitalInd
Emergency Room24 HrsYes (X)EmergencyRoom24HrsInd

Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1ROOSEVELT MEDICAL CENTERBusinessNameLine1Txt
FieldValueIRS element (for citing)
Facility1FacilityNum
First Licensed CY Or PYfalseFirstLicensedCYOrPYInd
Tax Exempt Hospital CY Or PYfalseTaxExemptHospitalCYOrPYInd
CHNA ConductedYes (true)CHNAConductedInd
Community DefinitionYes (X)CommunityDefinitionInd
Community DemographicsYes (X)CommunityDemographicsInd
Existing ResourcesYes (X)ExistingResourcesInd
How Data ObtainedYes (X)HowDataObtainedInd
Community Health NeedsYes (X)CommunityHealthNeedsInd
Other Health IssuesYes (X)OtherHealthIssuesInd
Community Hlth Needs Id ProcessYes (X)CommunityHlthNeedsIdProcessInd
Consulting ProcessYes (X)ConsultingProcessInd
Information GapsYes (X)InformationGapsInd
OtherYes (X)OtherInd
CHNA Conducted14CHNAConductedYr
Take Into Account Others InputYes (true)TakeIntoAccountOthersInputInd
CHNA Conducted With Other FcltsfalseCHNAConductedWithOtherFcltsInd
CHNA Conducted With Non FcltsfalseCHNAConductedWithNonFcltsInd
CHNA Report Widely AvailableYes (true)CHNAReportWidelyAvailableInd
Rpt Available On Own WebsiteYes (X)RptAvailableOnOwnWebsiteInd
Own Website URLROOSEVELTMEDICAL.ORGOwnWebsiteURLTxt
Paper Copy Public InspectionYes (X)PaperCopyPublicInspectionInd
Implementation Strategy AdoptYes (true)ImplementationStrategyAdoptInd
Implementation Strategy Adpt14ImplementationStrategyAdptYr
Strategy Posted WebsiteYes (true)StrategyPostedWebsiteInd
Strategy Website URLROOSEVELTMEDICAL.ORGStrategyWebsiteURLTxt
Strategy AttachedfalseStrategyAttachedInd
Organization Incur Excise TaxfalseOrganizationIncurExciseTaxInd
Elig Criteria ExplainedYes (true)EligCriteriaExplainedInd
FPG Family Incm Lmt Free DscntYes (X)FPGFamilyIncmLmtFreeDscntInd
FPG Family Incm Lmt Free Care100.000000000000FPGFamilyIncmLmtFreeCarePct
FPG Family Incm Lmt Dscnt Care200.000000000000FPGFamilyIncmLmtDscntCarePct
Medical Indigency CriteriaYes (X)MedicalIndigencyCriteriaInd
Insurance Status CriteriaYes (X)InsuranceStatusCriteriaInd
Underinsurance Stat CriteriaYes (X)UnderinsuranceStatCriteriaInd
Explained BasisYes (true)ExplainedBasisInd
App Financial Asst ExplnYes (true)AppFinancialAsstExplnInd
Described InfoYes (X)DescribedInfoInd
Described Suprt DocYes (X)DescribedSuprtDocInd
Provided Hospital ContactYes (X)ProvidedHospitalContactInd
Provided Nonprofit ContactYes (X)ProvidedNonprofitContactInd
Includes Publicity MeasuresYes (true)IncludesPublicityMeasuresInd
FAP Available On WebsiteYes (X)FAPAvailableOnWebsiteInd
FAP Available On Website URLWWWROOSEVELTMEDICALORGFAPAvailableOnWebsiteURLTxt
FAP App Available On WebsiteYes (X)FAPAppAvailableOnWebsiteInd
FAP App Available On Website URLWWWROOSEVELTMEDICALORGFAPAppAvailableOnWebsiteURLTxt
FAP Summary On WebsiteYes (X)FAPSummaryOnWebsiteInd
FAP Summary On Website URLWWWROOSEVELTMEDICALORGFAPSummaryOnWebsiteURLTxt
FAP Avlbl On Request No ChargeYes (X)FAPAvlblOnRequestNoChargeInd
FAP App Avlbl On Request No ChrgYes (X)FAPAppAvlblOnRequestNoChrgInd
FAP Sum Avlbl On Request No ChrgYes (X)FAPSumAvlblOnRequestNoChrgInd
FAP Notice DisplayedYes (X)FAPNoticeDisplayedInd
FAP Actions On NonpaymentYes (true)FAPActionsOnNonpaymentInd
Permit No ActionsYes (X)PermitNoActionsInd
Collection ActivitiesYes (true)CollectionActivitiesInd
FAP Notified Upon AdmissionYes (X)FAPNotifiedUponAdmissionInd
FAP Notified Before DischargeYes (X)FAPNotifiedBeforeDischargeInd
FAP Notified All PatientsYes (X)FAPNotifiedAllPatientsInd
Documented Elig DeterminationYes (X)DocumentedEligDeterminationInd
Nondis Emergency Care PolicyYes (true)NondisEmergencyCarePolicyInd
Other Method UsedYes (X)OtherMethodUsedInd
Amounts Generally BilledfalseAmountsGenerallyBilledInd
Gross ChargesfalseGrossChargesInd

Supplemental Information SupplementalInformationGrp (3 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
FACILITY 1, ROOSEVELT MEDICAL CENTER - PART V, LINE 5A RANDOM MAIL OUT SURVEY WAS DONE. A DEMOGRAPHIC BREAKDOWN WAS DONE FOR OUR DEFINED SERVICE AREA. THERE WAS A 22% RESPONSE.
FACILITY 1, ROOSEVELT MEDICAL CENTER - PART V, LINE 11THE FIRST STRATEGY FOR ADDRESSING THE SIGNIFICANT NEEDS IS TO UTILIZE A VARIETY OF COMMUNICATION STRATEGIES TO BETTER INFORM THE RMC SERVICE AREA OF HOSPITAL SERVICES, AS WELL AS INCREASE AND DIVERSIFY OUTREACH EFFORTS REGARDING SERVICES AVAILABLE AT RMC SUCH AS PUBLISHING A QUARTERLY HOSPITAL NEWSLETTER. THE SECOND STRATEGY FOR ADDRESSING THE SIGNIFICANT NEEDS IS TO EXPAND EXISTING COMMUNITY EDUCATION PROGRAMS AND EXPLORE OPPORTUNITIES TO START NEW PROGRAMS SUCH AS EXPLORING THE FEASIBILTY OF HOSTING A HEALTH FAIR AND PROMOTING THE EXISTING DIABETES EDUCATION PROGRAM. THE THIRD STRATEGY FOR ADDRESSING THE SIGNIFICANT NEEDS IS TO INCREASE AWARENESS OF LOCAL OPPORTUNITIES FOR PHYSICAL ACTIVITY SUCH AS PUBLISHING A SCHEDULE OF LOCAL CLASSES AND PHYSICAL ACTIVITY EVENTS IN HOSPITAL NEWSLETTERS AND EMAIL UPDATES. THE FOURTH STRATEGY FOR ADDRESSING THE SIGNIFICANT NEEDS IS TO EXPAND CURRENT PRIMARY CARE SERVICES AT RMC AND INCREASE PRIMARY CARE AND EMERGENCY ROOM COVERAGE SUCH AS RECRUITING AND HIRING AN ADDITIONAL PRIMARY CARE PROVIDER AND PROVIDING EDUCATION REIMBURSEMENT FOR HOSPITAL STAFF WHO WANT TO ADVANCE IN A HEALTH-RELATED FIELD. ONE OF THE IDENTIFIED HEALTH NEEDS WHICH WAS NOT ADDRESSED IS AFFORDABLE HOUSING. THIS IS A BROAD ISSUE THAT CANNOT BE ADDRESSED THROUGH THE HOSPITAL ALONE. THE COMMUNITY ALREADY HAS THE GREAT NORTHERN DEVELOPMENT ORGANIZATION THAT WAS CREATED TO ADDRESS THIS ISSUE. ANOTHER IDENTIFIED HEALTH NEED WHICH WAS NOT ADDRESSED WAS PROVIDING FULL- TIME SPECIALISTS. AT THIS TIME IT IS BEYOND THE RESOURCE CAPACITY OF ROOSEVELT MEDICAL CENTER. RMC OFFERS CONSULTS WITH SOME SPECIALISTS VIA TELEMEDICINE AND WORKS WITH BILLINGS CLINIC TO ADD MORE SPECIALITIES AS THE SPECIALISTS ARE WILLING TO PROVIDE TELEHEALTH SERVICES. RMC DOES NOT HAVE ENOUGH VOLUME OF PATIENTS IN ANY ONE SPECIALITY AREA TO GET SPECIALISTS TO TRAVEL HERE FOR ONSITE CONSULTS. TRANSPORTATION ASSISTANCE, DENTAL CLINIC, FITNESS CENTER, AND MASSAGE THERAPY ARE MORE IDENTIFIED HEALTH NEEDS WANTED BY THE COMMUNITY BUT PROVIDING THESE SERVICES IS BEYOND THE RESOURCE AND FINANCIAL CAPACITY OF RMC AT THE TIME OF THE IMPLEMENTATION PLAN. HOWEVER RMC DID HAVE AN INDEPENDENT MASSAGE THERAPIST AVAILABLE ON CAMPUS FROM 7/20/2015-8/31/2016. THE LAST IDENTIFIED HEALTH NEED WHICH WAS NOT ADDRESSED WAS PEOPLE INDICATED BEING UNAWARE OF PROGRAMS THAT WOULD HELP THEM PAY FOR THEIR HEALTHCARE BILLS. RMC HAS PAMPHLETS ABOUT FINANCIAL ASSISTANCE AVAILABLE IN THE CLINIC AND ER AND MAILS THEM OUT WHEN FINAL NOTICES ARE SENT FROM BILLING. WE HAVE HAD A CERTIFIED NAVIGATOR AND HELD PUBLIC MEETINGS THE PAST TWO YEARS TO EDUCATE THE PUBLIC ABOUT THE STATE HEALTH INSURANCE EXCHANGE. WE WILL CONTINUE TO PROVIDE INFORMATION ABOUT FINANCIAL ASSISTANCE IN NEWSLETTERS, OUR WEBSITE, AND OUR FACEBOOK PAGE TO INCREASE PUBLIC AWARENESS OF FINANCIAL ASSISTANCE OPTIONS FOR HEALTHCARE BILLS.
FACILITY 1, ROOSEVELT MEDICAL CENTER - PART V, LINE 22DOUR FACILITY INITIALLY CHARGES ONE RATE TO ALL PATIENTS WHETHER THEY ARE UNINSURED OR INSURED PER CMS GUIDELINES. THAT CHARGE MAY THEN BE DISCOUNTED BASED ON INSURANCE CONTRACTS, PREFERRED PROVIDER NETWORK AGREEMENTS, AND/OR QUALIFICATION FOR FINANCIAL ASSISTANCE. IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, THE PATIENTS BILLED CHARGES WILL BE NO MORE THAN THE SAME AMOUNTS GENERALLY BILLED (AGB) FOR EMERGENCY OR OTHER MEDICALLY NECESSARY HEALTH CARE SERVICES AS PATIENTS WHO HAVE INSURANCE COVERAGE. RMC WILL DETERMINE THE AGB BY USING THE INTERNAL REVENUE SERVICE'S PRESCRIBED 'LOOK BACK METHOD' BY MULTIPLYING FULL CHARGES FOR MEDICALLY NECESSARY CARE PROVIDED TO AN ELIGIBLE PATIENT BY THE AGB PERCENTAGE. THE AGB PERCENTAGE IS CALCULATED ANNUALLY AS OTHE SUM OF ALL ALLOWED (INCLUDING PAYMENT FROM BENEFICIARIES AND INSURERS) BY MEDICARE, MEDICAID, AND PRIVATE PAYERS DURING A PRIOR 12 MONTH PERIOD DIVIDED BY THE SUM OF GROSS CHARGES FOR THOSE CLAIMS. THE AGB PERCENTAGE FOR A 12 MONTH PERIOD WILL BE APPLIED NO LATER THAN 120 DAYS FOLLOWING THE END OF THE 12 MONTH MEASUREMENT PERIOD.
FieldValueIRS element (for citing)
Facility1FacilityNum

Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp

Oth Hlth Care Fclts OthHlthCareFcltsGrp

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1ROOSEVELT MEDICAL CENTER CLINICBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line1818 2ND AVE EAddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd
FieldValueIRS element (for citing)
FacilityRURAL HEALTH CLINICFacilityTxt

Supplemental Information Detail SupplementalInformationDetail (10 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
PART I, LINE 7G - SUBSIDIZED HEALTH SERVICES EXPLANATIONPHYSICIAN PROFESSIONAL SERVICES MAKE UP 192,427 OF COLUMN C, 131,077 OF COLUMN D, AND 61,349 OF COLUMN E. THE COST OF BAD DEBT REMOVED FROM THE COMMUNITY BENEFIT EXPENSE IN COLUMN C IS 19,597. ROOSEVELT MEDICAL CENTER'S EFFORTS TO RECRUIT AND RETAIN PHYSICIANS AND OTHER PROVIDERS ARE DEPENDENT ON OUR ABILITY TO COMPETE WITH ALL OTHER COMMUNITIES THAT ARE RECRUITING SIMILAR PHYSICIANS AND PROVIDERS. BECAUSE OF OUR SMALL COMMUNITY SIZE AND REMOTE LOCATION FAR REMOVED FROM MEDICAL COMMUNITIES OF GREATER SCOPE, WE EMPLOY PHYSICIANS AND SUBSIDIZE PHYSICIAN PRACTICES TO OFFER APPROPRIATELY COMPETITIVE SALARIES AND PRACTICE ENVIRONMENTS (SPECIFICALLY, REASONABLE CALL SCHEDULES). WE BELIEVE OUR ABILITY TO OFFER CORE NECESSARY PRIMARY CARE AND EMERGENCY SERVICES IS DEPENDENT ON SUBSIDIZATION.
PART I, LINE 7 - COSTING METHODOLOGY EXPLANATIONUSED ADJUSTED COST TO CHARGE RATIOS FOR PATIENT CARE FROM THE MEDICARE COST REPORT, ADJUSTED FOR BED TAX AND COMMUNITY BENEFIT. BAD DEBT EXPENSE AND CHARITY CARE ARE ALREADY EXCLUDED FROM THE MEDICARE COST REPORT.
PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGYTHE ORGANIZATION'S PATIENT CARE COST TO CHARGE RATIO, AFTER ELIMINATING BAD DEBT, CHARITY CARE, BED TAX, AND COMMUNITY BENEFIT EXPENSE, IS APPLIED TO GROSS BAD DEBT CHARGES TO ARRIVE AT THE COST OF BAD DEBT. DISCOUNTS REDUCE REVENUE AND ARE NOT RECORDED AS BAD DEBT. PAYMENTS RECEIVED ON PREVIOUSLY WRITTEN OFF ACCOUNTS ARE RECORDED AS RECOVERIES OF BAD DEBT WHICH REDUCE BAD DEBT EXPENSE. NONE OF THE BAD DEBT IS CONSIDERED ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE. BAD DEBTS ARE AN INEVITABLE RESULT OF OPERATING A NON PROFIT HOSPITAL.
BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTSTHE BAD DEBT EXPENSE FOOTNOTE IS ON PAGE 7 & 8 OF THE AUDITED FINANCIAL STATEMENTS.
PART III, LINE 8 - MEDICARE EXPLANATIONTHERE IS A MEDICARE SHORTFALL SINCE CRITICAL ACCESS HOSPITALS ARE REIMBURSED 101 PERCENT OF COST FROM MEDICARE FOR MOST SERVICES, LESS THE 2% SEQUESTRATION ADJUSTMENT, AND SOME SERVICES LIKE AMBULANCE ARE PAID BASED ON FEE SCHEDULES. MEDICARE COSTS ON PART III, LINE 6 ARE DIRECTLY FROM THE MEDICARE COST REPORT. MEDICARE REVENUE ON PART III, LINE 5 IS DIRECTLY FROM THE MEDICARE COST REPORT AND THE MEDICARE PROVIDER SUMMARY REPORT.
PART III, LINE 9B - COLLECTION PRACTICES EXPLANATIONIF APPROVED FOR FINANCIAL ASSISTANCE UNDER THE PROVISIONS OF THE FINANCIAL ASSISTANCE POLICY (FAP), THE PATIENT WILL RECEIVE NOTIFICATIONS THAT INCLUDE: A. THE DISCOUNT OF GROSS CHARGES TO THE AGB. THEN FINANCIAL ASSISTANCE DISCOUNTS WILL BE APPLIED TO THE AGB IN ACCORDANCE WITH THE DISCOUNT OF AGB CHARGES SCHEDULE DESCRIBED IN THE "DISCOUNT" SECTION OF THE FAP. B. PROVIDING THE PATIENT WITH A BILLING STATEMENT THAT INDICATES THE AMOUNT THE PATIENT OWES, IF THEY ARE NOT ELIGIBLE FOR FREE CARE. C. REFUNDING ANY EXCESS PAYMENTS MADE BY THE INDIVIDUAL BEYOND THE AGB ON ELIGIBLE ACCOUNTS IF NECESSARY. D. TAKING ALL REASONABLY AVAILABLE MEASURES TO REVERSE EXTRAORDINARY COLLECTION ACTIONS THAT OCCURRED.
PART VI, LINE 2 - NEEDS ASSESSMENTWE SEND OUT PATIENT SATISFACTION SURVEYS TO OUR PATIENTS.
PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCERMC WILL MAKE ALL REASONABLE EFFORTS TO NOTIFY A PATIENT REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER THIS POLICY BY: 1.ATTEMPTING TO DETERMINE WHETHER A PATIENT HAS THIRD-PARTY COVERAGE FOR ANY PART OF THE EMERGENCY OR MEDICALLY NECESSARY HEALTH CARE SERVICE PROVIDED. IF A PATIENT DOES NOT HAVE OR QUALIFY FOR THIRD-PARTY FUNDING, THE BUSINESS OFFICE STAFF WILL EXPLAIN THE FINANCIAL ASSISTANCE POLICY, PROVIDE AN APPLICATION FOR FINANCIAL ASSISTANCE AND PROVIDE ASSISTANCE WITH COMPLETING THE APPLICATION, IF DESIRED. 2.OFFERING THE PATIENT A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE AVAILABLE UNDER THIS POLICY AT THE TIME OF ADMISSION OR BEFORE DISCHARGE FROM RMC. 3.PROVIDING THE INFORMATION DURING THE NOTIFICATION PERIOD ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE ON AT LEAST THREE (3) BILLING STATEMENTS AND IN ALL OTHER WRITTEN COMMUNICATIONS IN REFERENCE TO FINANCIAL RECORDS TO THE PATIENT; 4.INFORMING PATIENTS DURING THE NOTIFICATION PERIOD ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE DURING ORAL COMMUNICATIONS REGARDING THE AMOUNT DUE FOR THE CARE THAT OCCURRED; 5.PROVIDING THE PATIENT WITH AT LEAST ONE WRITTEN NOTICE INFORMING THE PATIENT ABOUT THE EXTRAORDINARY COLLECTION ACTIONS THAT RMC MAY TAKE IF THE PATIENT DOES NOT SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE OR PAY THE AMOUNT DUE BY AT LEAST THIRTY DAYS FOLLOWING THE DATE OF THE NOTICE. THE NOTICE WILL NOT BE MAILED OR DELIVERED TOA PATIENT EARLIER THAN 30 DAYS PRIOR TO THE END OF THE NOTIFICATION PERIOD; AND 6.RMC WILL NOT ENGAGE IN ANY EXTRAORDINARY COLLECTION ACTIONS AGAINST A PATIENT UNTIL SUCH TIME AS IT DETERMINES THE PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE UNDER THIS POLICY DURING THE 120 DAY NOTIFICATION PERIOD AND HAS PROVIDED THE PATIENT WITH THE NOTICE AS DESCRIBED ABOVE.
PART VI, LINE 4 - COMMUNITY INFORMATIONWE PROVIDE SERVICE TO THE POPULATION IN EASTERN ROOSEVELT COUNTY, SOUTHERN SHERIDAN COUNTY, AND NORTHERN RICHLAND COUNTY.
PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTHTHE ADMINISTRATOR OF ROOSEVELT MEDICAL CENTER PARTICIPATES IN THE LOCAL CHAMBER OF COMMERCE.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Written Employment ContractYes (X)WrittenEmploymentContractInd
Compensation SurveyYes (X)CompensationSurveyInd
Board Or Committee ApprovalYes (X)BoardOrCommitteeApprovalInd
Severance PaymentfalseSeverancePaymentInd
Supplemental Nonqual Rtr PlanfalseSupplementalNonqualRtrPlanInd
Equity Based Comp ArrngmfalseEquityBasedCompArrngmInd
Comp Based On Revenue Of Flng OrgfalseCompBasedOnRevenueOfFlngOrgInd
Comp Bsd On Rev Related OrgsfalseCompBsdOnRevRelatedOrgsInd
Comp Bsd Net Earns Flng OrgfalseCompBsdNetEarnsFlngOrgInd
Comp Bsd Net Earns Rltd OrgsfalseCompBsdNetEarnsRltdOrgsInd
Any Non Fixed PaymentsfalseAnyNonFixedPaymentsInd
Initial Contract ExceptionfalseInitialContractExceptionInd

Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)

TitleTitleTxtBase Compensation Filing OrgBaseCompensationFilingOrgAmtDeferred Compensation Flng OrgDeferredCompensationFlngOrgAmtNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmtTotal Compensation Filing OrgTotalCompensationFilingOrgAmt
DON HELLAND
MD$197,586$300$4,901$202,787
ELIZABETH KLEPPEN
PA-C$163,684$300$5$163,989

Schedule M IRS990ScheduleM

Other Non Cash Contri Table OtherNonCashContriTableGrp

FieldValueIRS element (for citing)
Non Cash CheckboxYes (X)NonCashCheckboxInd
DescMEDICAL EQUIP.Desc
Contribution1ContributionCnt
Noncash Contributions Rpt F990$44,000NoncashContributionsRptF990Amt
Method Of Determining RevenuesFAIR VALUEMethodOfDeterminingRevenuesTxt
FieldValueIRS element (for citing)
Any Property That Must Be HeldfalseAnyPropertyThatMustBeHeldInd
Review Process Unusual NC GiftsfalseReviewProcessUnusualNCGiftsInd
Third Parties UsedfalseThirdPartiesUsedInd

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (7 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
FORM 990, PAGE 6, PART VI, LINE 2PAULA SCHLEDEWITZ GRANT SALVEVOLD CHAIR DIRECTOR PAULA IS HIS AUNT BY MARRIAGE. SHARON SCHMITZ JESSICA SCHMITZ DIRECTOR DON SHARON IS JESSICA'S MOTHER. JO NELSON MARK NELSON DIRECTOR WE MAINT DEP JO IS MARK'S SPOUSE.
FORM 990, PAGE 6, PART VI, LINE 11BFORM 990 IS REVIEWED AT A REGULAR BOARD MEETING.
FORM 990, PAGE 6, PART VI, LINE 12CCOMPLIANCE IS REVIEWED ANNUALLY.
FORM 990, PAGE 6, PART VI, LINE 15ATHE ADMINISTRATOR'S COMPENSATION IS APPROVED BY THE BOARD OF DIRECTORS WHICH IS USUALLY BASED ON THE AMOUNT/PERCENTAGE OF RAISE THE REST OF THE EMPLOYEES ARE GOING TO RECEIVE.
FORM 990, PAGE 6, PART VI, LINE 15BCFO COMPILES INFORMATION FROM ANNUAL MHA SALARY SURVEY REGARDING AVERAGE WAGE BEING PAID FOR EACH JOB DESCRIPTION BASED ON PEER GROUP, CAH'S, OR MHA REGION. CFO AND CEO COMPARE AVERAGES BEING PAID TO CURRENT ROOSEVELT MEDICAL CENTER SALARY SCALE TO SEE IF ADJUSTMENTS NEED TO BE MADE TO KEEP JOB COMPETITIVE WITHIN INDUSTRY. RECOMMENDATIONS FOR SALARY INCREASES ARE MADE TO THE BOARD OF DIRECTORS FOR APPROVAL OR DISAPPROVAL WHICH IS RECORDED IN THE BOARD MINUTES.
FORM 990, PAGE 6, PART VI, LINE 19DOCUMENTS RELATING TO ROOSEVELT MEDICAL CENTER ARE AVAILABLE UPON REQUEST.
FORM 990, PART IX, LINE 11GADMIN PROF FEES 0 39,620 0 ADMIN PURCHASED SERVICES 0 3,181 0 CLINIC PROF FEES 12,616 0 0 DIETARY PURCHASED SERVICES 268,411 0 0 LAB PROF FEES 125,501 0 0 LAB PURCHASED SERVICES 40,679 0 0 MAINT PURCHASED SERVICES 0 218 0 MEDICAL & SURGICAL PROF FEES 20,038 0 0 MEDICAL & SURGICAL PURCH SVCS 17,468 0 0 MEDICAL RECORDS PURCH SRVCS 7,608 0 0 OT PURCHASED SERVICES 16,656 0 0 PT PURCHASED SERVICES 69,065 0 0 RADIOLOGY PROF FEES 4,898 0 0 RADIOLOLGY PURCHASED SERVICES 9,891 0 0 ST PURCHASED SERVICES 7,025 0 0 SWING BED PROF FEES 250,210 0 0 ER PROF FEES 15,268 0 0

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp

Disregarded Entity Name DisregardedEntityName

FieldValueIRS element (for citing)
Business Name Line1ROOSEVELT MEMORIAL HEALTHCARE FOUNDBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 419AddressLine1Txt
CityCULBERTSONCityNm
State AbbreviationMTStateAbbreviationCd
ZIP59218ZIPCd
FieldValueIRS element (for citing)
EIN810529284EIN
Primary ActivitiesSUPPORT ORPrimaryActivitiesTxt
Legal Domicile StateMTLegalDomicileStateCd
Exempt Code Section501C3ExemptCodeSectionTxt
Public Charity Status7PublicCharityStatusTxt
Direct Controlling NAN/ADirectControllingNACd
Controlled OrganizationfalseControlledOrganizationInd
FieldValueIRS element (for citing)
Receipt Of Int Annts Rnts RyltsfalseReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth OrgfalseGiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth OrgYes (true)GiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth OrgfalseLoansOrGuaranteesFromOthOrgInd
Div Related OrganizationfalseDivRelatedOrganizationInd
Asset Sale To Other OrgfalseAssetSaleToOtherOrgInd
Asset Purchase From Other OrgfalseAssetPurchaseFromOtherOrgInd
Asset ExchangefalseAssetExchangeInd
Rental Of Facilities To Oth OrgfalseRentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth OrgfalseRentalOfFcltsFromOthOrgInd
Perform Of Services For Oth OrgfalsePerformOfServicesForOthOrgInd
Perform Of Services By Other OrgfalsePerformOfServicesByOtherOrgInd
Sharing Of FacilitiesYes (true)SharingOfFacilitiesInd
Paid Employees SharingYes (true)PaidEmployeesSharingInd
Reimbursement Paid To Other OrgfalseReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrgInd
Transfer To Other OrgfalseTransferToOtherOrgInd
Transfer From Other OrgfalseTransferFromOtherOrgInd

Transactions Related Org TransactionsRelatedOrgGrp (2 entries)

Transaction TypeTransactionTypeTxtInvolvedInvolvedAmtMethod Of Amount DeterminationMethodOfAmountDeterminationTxt
ROOSEVELT MEMORIAL HEALTHCARE FOUND
C$62,247SUPPORT
ROOSEVELT MEMORIAL HEALTHCARE FOUND
O$30,604WAGES FOR RMHF DIRECTOR