CHEYENNE COUNTY HOSPITAL ASSOCIATION INC: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- CHEYENNE COUNTY HOSPITAL ASSOCIATION INC (EIN 47-0408242)
- Tax period
- 2015-01-01 to 2015-12-31
- Filed
- 2016-11-14
- IRS object ID
- 201633199349309918
- Schema version
- 2015v2.1
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-11-14T15:59:00-06:00 | ReturnTs |
| Tax Period End | 2015-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470408242 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CHEY | BusinessNameControlTxt |
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JASON PETIK | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3082545825 | PhoneNum |
| Signature | 2016-11-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | WENDY R COOLEY | PreparerPersonNm |
| PTIN | P01523804 | PTIN |
| Phone | 4023302660 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Change | Yes (X) | AddressChangeInd |
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIDNEY REGIONAL MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JASON PETIK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $52,524,955 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1951 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 13 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 10 | VotingMembersIndependentCnt |
| Total Employee | 516 | TotalEmployeeCnt |
| Total Volunteers | 64 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $48,282 | PYContributionsGrantsAmt |
| CY Contributions Grants | $182,617 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $46,715,832 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $52,158,301 | CYProgramServiceRevenueAmt |
| PY Investment Income | $54,663 | PYInvestmentIncomeAmt |
| CY Investment Income | -$142,457 | CYInvestmentIncomeAmt |
| PY Other Revenue | $114,328 | PYOtherRevenueAmt |
| CY Other Revenue | $114,857 | CYOtherRevenueAmt |
| PY Total Revenue | $46,933,105 | PYTotalRevenueAmt |
| CY Total Revenue | $52,313,318 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $23,854 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $76,043 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $25,090,232 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $28,499,642 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $16,380,325 | PYOtherExpensesAmt |
| CY Other Expenses | $19,667,482 | CYOtherExpensesAmt |
| PY Total Expenses | $41,494,411 | PYTotalExpensesAmt |
| CY Total Expenses | $48,243,167 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $5,438,694 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $4,070,151 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $58,646,230 | TotalAssetsBOYAmt |
| Total Assets EOY | $88,576,422 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $19,754,255 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $49,324,233 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $38,891,975 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $39,252,189 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $38,072,966 | ExpenseAmt |
| Grant | $76,043 | GrantAmt |
| Revenue | $35,974,309 | RevenueAmt |
| Desc | SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN SIDNEY, NEBRASKA. IT ALSO OPERATES LONG-TERM CARE FACILITIES, A HOME HEALTH AGENCY, AND PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA AND CHAPPELL, NEBRASKA, AS WELL AS A STAND ALONE PRIMARY CARE CLINIC IN SIDNEY, NEBRASKA. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,472,362 | ExpenseAmt |
| Revenue | $7,197,772 | RevenueAmt |
| Desc | IN 2015, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,718 PATIENT DAYS OF CARE, INCLUDING INPATIENT AND OBSERVATION PATIENTS, AND DELIVERED 77 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,493 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2015. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,573,951 | ExpenseAmt |
| Revenue | $3,885,319 | RevenueAmt |
| Desc | THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 53 PATIENTS DAILY DURING 2015. SRMC PROVIDED 19,487 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,455,506 | ExpenseAmt |
| Revenue | $5,100,901 | RevenueAmt |
| Desc | THE SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $2,455,506 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Revenue | $5,100,901 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $46,574,785 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 85 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 516 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 13 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 10 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KELLY UTLEY | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (20 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| WILLIAM PILE | ||||||||
| CHAIRMAN | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TIM MILLER | ||||||||
| VICE CHAIRMAN | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TOM MILLMAN | ||||||||
| SECRETARY | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JEFF ELLWANGER | ||||||||
| TREASURER | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| STAN BELIEU | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| CLINTON DORWART MD | ||||||||
| MEMBER - CHIEF OF MEDICAL STAFF | 40.00 | 0.00 | Yes (X) | $183,337 | $0 | $8,521 | ||
| JIM JONES | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| KATHY NARJES | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ROB ROBINSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| MANDY SHAW MD | ||||||||
| MEMBER - PHYSICIAN AT LARGE | 40.00 | 0.00 | Yes (X) | $334,359 | $0 | $10,260 | ||
| DWIGHT SMITH | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JULIE WAMSLEY | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| LAURIE WIDDOWSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JASON PETIK | ||||||||
| CEO | 40.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| KELLY UTLEY | ||||||||
| CFO | 39.00 | 1.00 | Yes (X) | $153,803 | $0 | $35,718 | ||
| REBECCA L ALLARD MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $357,518 | $0 | $53,144 | Yes (X) | ||
| JAMES THAYER MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $338,586 | $0 | $36,392 | Yes (X) | ||
| MICHAEL L MATTHEWS MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $304,900 | $0 | $12,024 | Yes (X) | ||
| DAVID MANKE | ||||||||
| CRNA | 40.00 | 0.00 | $267,507 | $0 | $46,176 | Yes (X) | ||
| JENNIFER BROWN MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $254,493 | $0 | $32,400 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $2,194,503 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $234,635 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 34 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| RURAL PARTNERS IN MEDICINE LLC | |||||
| PO BOX 772519 | STEAMBOAT SPRINGS | CO | 80477 | PHYSICIAN SERVICES | $1,763,330 |
| BYTES COMPUTER & NETWORK SOLUTIONS INC | |||||
| 1712 AVENUE B | SCOTTSBLUFF | NE | 69361 | IT SERVICES | $337,475 |
| UNIVERSITY OF COLORADO HOSPITAL AUTHORIT | |||||
| PO BOX 733156 | DALLAS | TX | 75373 | MANAGEMENT SERVICES | $290,890 |
| SHARED MEDICAL SERVICES INC | |||||
| 209 LIMESTONE PASS | COTTAGE GROVE | WI | 53527 | MRI LEASE | $214,800 |
| FUSION MEDICAL STAFFING LLC | |||||
| PO BOX 82764 | LINCOLN | NE | 68501 | TEMPORARY STAFFING | $188,837 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 12 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $158,862 | RelatedOrganizationsAmt |
| Government Grants | $20,158 | GovernmentGrantsAmt |
| All Other Contributions | $3,597 | AllOtherContributionsAmt |
| Total Contributions | $182,617 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621110 | $31,506,911 | $31,506,911 |
| MEDICARE/MEDICAID | 621110 | $20,120,005 | $20,120,005 |
| 340B REVENUE | 621110 | $191,017 | $191,017 |
| SCHOOL REHAB REVENUE | 621110 | $76,382 | $76,382 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $263,986 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $263,986 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $52,158,301 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $68,680 | TotalRevenueColumnAmt |
| Exclusion | $68,680 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $500 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $211,637 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -$211,137 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$211,137 | TotalRevenueColumnAmt |
| Exclusion | -$211,137 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| CAFETERIA | 722210 | $107,540 | $107,540 |
| PATRONAGE DIVIDEND | 900099 | $7,317 | $7,317 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $114,857 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $52,313,318 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $52,158,301 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | -$27,600 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $76,043 | TotalAmt |
| Program Services | $76,043 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $725,999 | TotalAmt |
| Program Services | $536,477 | ProgramServicesAmt |
| Management And General | $189,522 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $70,137 | TotalAmt |
| Management And General | $70,137 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $20,166,349 | TotalAmt |
| Program Services | $19,927,025 | ProgramServicesAmt |
| Management And General | $239,324 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $603,745 | TotalAmt |
| Program Services | $599,838 | ProgramServicesAmt |
| Management And General | $3,907 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,534,908 | TotalAmt |
| Program Services | $5,439,899 | ProgramServicesAmt |
| Management And General | $95,009 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,398,504 | TotalAmt |
| Program Services | $1,340,319 | ProgramServicesAmt |
| Management And General | $58,185 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $290,890 | TotalAmt |
| Management And General | $290,890 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $58,339 | TotalAmt |
| Management And General | $58,339 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $76,533 | TotalAmt |
| Management And General | $76,533 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,757,872 | TotalAmt |
| Program Services | $5,670,912 | ProgramServicesAmt |
| Management And General | $86,960 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $261,204 | TotalAmt |
| Program Services | $261,204 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $905,963 | TotalAmt |
| Program Services | $840,900 | ProgramServicesAmt |
| Management And General | $65,063 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $557,933 | TotalAmt |
| Program Services | $557,933 | ProgramServicesAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $986,520 | TotalAmt |
| Program Services | $986,520 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $169,941 | TotalAmt |
| Program Services | $150,258 | ProgramServicesAmt |
| Management And General | $19,683 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $164 | TotalAmt |
| Management And General | $164 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $100,453 | TotalAmt |
| Management And General | $100,453 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,116,051 | TotalAmt |
| Program Services | $1,886,599 | ProgramServicesAmt |
| Management And General | $229,452 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $323,045 | TotalAmt |
| Program Services | $323,045 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $6,590,582 | $6,590,582 | |
| BAD DEBTS | $805,705 | $805,705 | |
| FOOD PRODUCTS | $399,131 | $399,131 | |
| DUES AND SUBSCRIPTIONS | $150,143 | $84,490 | $65,653 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $117,013 | TotalAmt |
| Program Services | $97,905 | ProgramServicesAmt |
| Management And General | $19,108 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $48,243,167 | TotalAmt |
| Program Services | $46,574,785 | ProgramServicesAmt |
| Management And General | $1,668,382 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,793,700 | BOYAmt |
| EOY | $3,036,482 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,805,948 | BOYAmt |
| EOY | $16,162,753 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,427,622 | BOYAmt |
| EOY | $7,383,901 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $193,641 | BOYAmt |
| EOY | $82,808 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,458,752 | BOYAmt |
| EOY | $1,225,788 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $597,234 | BOYAmt |
| EOY | $554,981 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $67,748,914 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $8,858,045 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,201,664 | BOYAmt |
| EOY | $58,890,869 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,423 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,160,246 | BOYAmt |
| EOY | $1,238,840 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $58,646,230 | BOYAmt |
| EOY | $88,576,422 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,946,690 | BOYAmt |
| EOY | $9,251,052 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,100,002 | BOYAmt |
| EOY | $7,192,417 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $240,361 | BOYAmt |
| EOY | $32,342,914 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $467,202 | BOYAmt |
| EOY | $537,850 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,754,255 | BOYAmt |
| EOY | $49,324,233 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $38,891,975 | BOYAmt |
| EOY | $39,252,189 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $38,891,975 | BOYAmt |
| EOY | $39,252,189 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $58,646,230 | BOYAmt |
| EOY | $88,576,422 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $4,070,151 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$3,709,937 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $5,593 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $5,593 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $92,500 | InvestmentCostOrOtherBasisAmt |
| Other Cost Or Other Basis | $1,867,557 | OtherCostOrOtherBasisAmt |
| Book Value | $1,960,057 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $48,748,024 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,362,547 | DepreciationAmt |
| Book Value | $45,385,477 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $21,420 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,200 | DepreciationAmt |
| Book Value | $15,220 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $16,102,732 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,278,984 | DepreciationAmt |
| Book Value | $10,823,748 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $916,681 | OtherCostOrOtherBasisAmt |
| Depreciation | $210,314 | DepreciationAmt |
| Book Value | $706,367 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $58,890,869 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| DEFERRED COMPENSATION PLAN LIABILITY | $537,333 |
| DUE TO AFFILIATES | $517 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $537,850 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2015, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $765,029 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $765,029 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01610 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,807,072 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,528,404 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $278,668 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00590 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,572,101 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,528,404 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,043,697 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02200 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $245,720 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $64,742 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $180,978 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00380 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $45,710 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $45,710 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00100 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $86,230 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $86,230 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00180 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $377,660 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $64,742 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $312,918 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00660 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,949,761 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,593,146 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,356,615 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02860 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 84 | ActivitiesOrProgramsCnt |
| Persons Served | 2008 | PersonsServedCnt |
| Total Community Benefit Expns | $3,588 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,588 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 9 | ActivitiesOrProgramsCnt |
| Persons Served | 560 | PersonsServedCnt |
| Total Community Benefit Expns | $942 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $942 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Other Communtity Building Acty OtherCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 254 | ActivitiesOrProgramsCnt |
| Persons Served | 6153 | PersonsServedCnt |
| Total Community Benefit Expns | $29,689 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $29,689 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00060 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 347 | ActivitiesOrProgramsCnt |
| Persons Served | 8721 | PersonsServedCnt |
| Total Community Benefit Expns | $34,219 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $34,219 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $805,705 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $281,997 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $14,118,919 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $14,497,275 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$378,356 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| State License | 150001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 14 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.SIDNEYRMC.COM | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | WWW.PPHD.ORG | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 14 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.SIDNEYRMC.COM | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 3J: THE NEEDS ASSESSMENT INDICATES OVERALL LEVEL OF HEALTH, INCLUDING WEIGHT, ACTIVITY AND LIFESTYLE CONCERNS. ALTHOUGH THERE IS A GROWING CONCERN OF SUBSTANCE ABUSE AMONG THE GENERAL POPULATION; SUBSTANCE ABUSE IS CONSIDERABLY LOW DUE TO SOCIAL AND PHYSICAL LOCATION OF THE COMMUNITY. DUE TO LIMITED HEALTHY FOOD OPTIONS IN THE REGION THE AMOUNT OF OVER WEIGHT INDIVIDUALS INCREASES. INCREASED USE OF ELECTRONICS HAS INCREASED INACTIVITY IN YOUTH. OTHER DETERMINANTS INCLUDE LACK OF TIME AND AVAILABILITY FOR PHYSICAL ACTIVITY FOR WORKING POPULATION FROM THE EXCESSIVE AMOUNT OF HOURS BEING WORKED. THE GOALS THAT WE WILL TRY TO ACHIEVE ARE AS FOLLOWS: (1) NUTRITION AND WEIGHT STATUS (2) PHYSICAL ACTIVITY (3) SUBSTANCE ABUSE AND (4) HAND HYGIENE. THROUGH THESE INITIATIVES WE PLAN TO IMPROVE THE LEVEL OF HEALTHY LIVING FOR THE MEMBERS OF THE COMMUNITY BY REDUCING THE OBESITY IN ADULTS AND IMPROVING THE AMOUNT OF PHYSICAL ACTIVITY FOR ADULTS THROUGH TARGETED FITNESS GOALS. EQUALLY IMPORTANT IS THE DECREASE OF PHARMACEUTICAL, ILLEGAL AND RECREATIONAL DRUG USE. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 5: SIDNEY REGIONAL MEDICAL CENTER HOSTED THREE FOCUS GROUPS ON JUNE 24, 2014. THERE WERE A TOTAL OF 30 PEOPLE ATTENDING ONE OF THE THREE SESSIONS. ONE GROUP REPRESENTED THE GENERAL POPULATION OF THE COMMUNITY, ONE GROUP REPRESENTED THE HISPANIC POPULATION AND THE THIRD GROUP REPRESENTED THE SMALL COMMUNITY OF CHAPPELL, NEBRASKA IN DEUEL COUNTY LOCATED APPROXIMATELY 20 MILES EAST OF SIDNEY. A STAKEHOLDER MEETING WAS HELD IN JULY TO ESTABLISH VISION FOR CHEYENNE AND DEUEL COUNTIES. PARTICIPANTS INCLUDED REPRESENTATIVES FROM THE HOSPITAL, PUBLIC SCHOOL SYSTEM, MEDIA, CHAMBER OF COMMERCE, LOCAL BUSINESSES, NON-PROFIT AND SERVICE ORGANIZATIONS, FAITH-BASED ORGANIZATIONS, LAW ENFORCEMENT AND THE CITY OF SIDNEY. OVER THE COURSE OF THE MEETING, THE PARTICIPANTS WERE PRESENTED WITH HEALTH DATA, SOCIOECONOMIC DATA, INCLUDING THE LEADING CAUSES OF DEATH FOR THE PANHANDLE COMPARED TO THE REST OF THE STATE, THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES (ACE) AND CHILD WELL-BEING DATA. PRESENTERS ALSO GAVE AN OUTLINE OF THE CURRENT PRIORITY AREAS OF THE PANHANDLE HEALTH IMPROVEMENT PLAN. THE RESULTS OF THE STAKEHOLDER MEETING, FOCUS GROUPS, HEALTH DATA AND RESULTS FROM A COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY WERE PRESENTED TO A SMALLER COMMITTEE OF SRMC STAFF IN NOVEMBER 2014 TO DETERMINE PRIORITY AREAS. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-GARDEN COUNTY HEALTH SERVICES, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-SCOTTSBLUFF COUNTY HEALTH DEPARTMENT, SCOTTSBLUFF, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 11: IN ORDER TO ADDRESS NUTRITION AND WEIGHT STATUS THE HOSPITAL IS PROVIDING EDUCATION TO THE COMMUNITY ON HOW TO MAKE HEALTHY FOOD CHOICES DURING THE CURRENT YEAR. IN ORDER TO ADDRESS PHYSICAL ACTIVITY THE HOSPITAL IS PARTNERING WITH THE AREA COMMUNITY CENTER TO TRACK EMPLOYEE ACTIVITY THROUGH WELLNESS PROGRAMS. THE HOSPITAL PROVIDED THREE, 16-WEEK PROGRAMS REGARDING PHYSICAL ACTIVITY. THEY ALSO TAUGHT COMMUNITY MEMBERS TO TRACK THE NUMBER OF MINUTES THEY EXERCISED DURING THE PROGRAM. ADDITIONAL PLANNING AND OUTDOOR ACTIVITIES ARE BEING COORDINATED. THE HOSPITAL HAS PLANS IN THE NEXT THREE YEARS TO PARTNER WITH LAW ENFORCEMENT AND MENTAL HEALTH INSTITUTIONS TO CREATE DRUG INTERACTION EVALUATION REVIEWS. EDUCATION IS ALSO BEING DEVELOPED FOR HAND HYGIENE TECHNIQUES FOR DISTRIBUTION TO CHILDREN AND ADULTS DURING FALL OF 2016.DURING THE COMMUNITY NEEDS ASSESSMENT PROCESS, SEVERAL ITEMS WERE IDENTIFIED BY COMMUNITY MEMBERS THAT WERE NOT CHOSEN BY THE HOSPITAL TO BE INCLUDED IN THEIR HEALTH PLANS. THESE ITEMS INCLUDE ANIMAL HEALTH AND WELLNESS, A DOG PARK, RETIREMENT COMMUNITY ACTIVITIES, BIKER-FRIENDLY LANES ON STREETS AND NEIGHBORHOOD INTERACTION BETWEEN COMMUNITY MEMBERS. WHILE EACH OF THESE ITEMS IN SOME WAY AFFECT HUMAN HEALTH, AND THEREFORE COMMUNITY HEALTH, THE HOSPITAL CHOSE TO FOCUS ON HEALTH ISSUES IT COULD DIRECTLY AFFECT WHEN MAKING DECISIONS ABOUT WHAT TO ADDRESS AND WHAT NOT TO ADDRESS FROM A HOSPITAL SYSTEM LEVEL. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 13B: CHARITY CARE, KNOWN AS SRMC FINANCIAL ADJUSTMENT PROGRAM, IS GENERALLY SECONDARY TO ALL OTHER PATIENT FINANCIAL RESOURCES. SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENTS WITH NO KNOWN ESTATE OR SPOUSE, PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES, OR A PATIENT HOMELESS OR WITHOUT RESOURCES. PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE, PERSONAL PROPERTY AND INVESTMENT EQUITY, WITH CREDIT GIVEN FOR ALREADY EXISTING MEDICAL LOANS IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. FREE CARE WILL BE GIVEN TO HOUSEHOLDS THAT ARE AT 100% OF POVERTY LEVEL. DISCOUNTED CARE WILL BE PROVIDED TO HOUSEHOLDS WITH INCOMES UP TO 300% OF THE POVERTY LEVEL. SRMC'S PRACTICE FOR ADDITIONAL DISCOUNTED CARE IS THROUGH THE TRUE PRIVATE PAY POLICY. IF A PATIENT HAS NO INSURANCE THE PATIENT WILL BE OFFERED A DISCOUNT EQUIVALENT TO THAT WHICH WOULD BE DISCOUNTED ON A CONTRACTUAL BASIS WITH COMMERCIAL PAYERS IF THEIR PAYMENT IS RECEIVED IN 45 DAYS. THE PROBABILITY OF THIS HAPPENING IS HIGH DUE TO A LOAN PROGRAM THAT SRMC HAS WITH A LOCAL BANKING INSTITUTION ALLOWING IMMEDIATE PAYMENT AT THE PATIENT'S REQUEST. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 16I: THE POLICY IS REFERENCED IN BILLING STATEMENTS AND IS VERBALLY REVIEWED THROUGH MANY AVENUES IN ADMISSIONS AND PATIENT FINANCIAL SERVICES, INCLUDING PATIENT ADVOCACY. THE POLICY IS AVAILABLE IN THE WAITING ROOMS AT THE HOSPITAL. ADDITIONALLY, FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH COULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. A HARDCOPY OF THE POLICY IS OFFERED BY THE PATIENT ADVOCATE/FINANCIAL COUNSELOR DURING MEETINGS WITH PATIENTS. MEDICAID PATIENTS AUTOMATICALLY QUALIFY AT 100%. THE CHARITY CARE POLICY IS ALSO SENT TO EVERY BAD DEBT ACCOUNT GUARANTOR PRIOR TO THEIR ACCOUNT BEING TURNED IN TO A COLLECTION AGENCY FOR NON-PAYMENT. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 22D: ELIGIBLE PATIENTS UNDER THE FINANCIAL ASSISTANCE POLICY RECEIVE AN ADJUSTMENT ON A PERCENTAGE BASIS. THE ADJUSTMENT IS CALCULATED USING SOFTWARE WHICH TAKES INTO ACCOUNT THEIR INCOME, HOUSEHOLD STATUS, ETC. IN COMPLIANCE WITH THE POLICY. TRUE PRIVATE PAY INDIVIDUALS (UNINSURED) RECEIVE AN IMMEDIATE REDUCTION IN CHARGES EQUIVALENT TO AN AVERAGE COMMERCIAL RATE. FAP ELIGIBLE PATIENTS MAY RECEIVE A REDUCTION UP TO 100% OF CHARGES RESULTING IN ZERO CHARGES TO THOSE INDIVIDUALS. FAP ELIGIBLE PATIENTS WHO ARE ELIGIBLE FOR THE 70% OR 100% DISCOUNTS ARE NOT BILLED MORE THAN THE LOWEST COMMERCIAL RATE OR MEDICAID RATE AS THESE RATES ARE HIGHER THAN 30% OF CHARGES. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE | ||||
| 1000 POLE CREEK CROSSING | SIDNEY | NE | 69162 | LONG TERM CARE FACILITY |
| 2 - SLOAN ESTATES ASSISTED LIVING | ||||
| 2550 CRAIG AVENUE | SIDNEY | NE | 69162 | ASSISTED LIVING |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. |
| PART I, LINE 6A: | THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER. |
| PART I, LINE 7: | THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. |
| PART I, LINE 7G: | THERE ARE NO SUBSIDIZED HEALTH SERVICES. |
| PART I, LN 7 COL(F): | BAD DEBT EXPENSE OF $805,705 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. COMMUNITY HEALTH IMPROVEMENT INCLUDES COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. |
| PART III, LINE 2: | IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE SYSTEM RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. |
| PART III, LINE 3: | SIDNEY REGIONAL MEDICAL CENTER HAS ESTIMATED THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO MAY HAVE BEEN ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY AT 40%. THIS ESTIMATE IS BASED ON A RECOVERY RATE FROM THE COLLECTION AGENCY FOR 2015 ACCOUNTS OF APPROXIMATELY 30%. THEORETICALLY, THE NEARLY 30% WHICH HAS BEEN RECOVERED IS BEING RECOVERED FROM PEOPLE WHO COULD PAY BUT DIDN'T. WHEN ESTIMATING THAT POSSIBLY HALF OF THE REMAINING 70% OF THE BAD DEBT WAS ATTRIBUTABLE TO PATIENTS WHO HAD NO MEANS OF PAYMENT RATHER THAN MEANS BUT NO INTENT, THIS ESTIMATE OF FAP AMOUNTS IN BAD DEBT WOULD TOTAL APPROXIMATELY 35%. NONE OF THIS AMOUNT IS CONSIDERED TO BE COMMUNITY BENEFIT. |
| PART III, LINE 4: | THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 9, AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE AND "CHARITY CARE". |
| PART III, LINE 8: | THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2015 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. |
| PART III, LINE 9B: | THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. |
| PART VI, LINE 3: | AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEETINGS WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. |
| PART VI, LINE 4: | THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2015. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 43.7. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2015. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. |
| PART VI, LINE 5: | SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2015 AS A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST-BASED REIMBURSED AND, IN FACT, ERODE THE COST-BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. |
| PART VI, LINE 6: | SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Recipient EINRecipientEIN | IRC SectionIRCSectionDesc | Cash GrantCashGrantAmt | Non Cash AssistanceNonCashAssistanceAmt | Purpose Of GrantPurposeOfGrantTxt |
|---|---|---|---|---|---|---|---|---|
| CITY OF SIDNEY | ||||||||
| 1115 13TH AVENUE PO BOX 79 | SIDNEY | NE | 69162 | 476006361 | GOVERNMENTAL | $50,000 | $0 | TO SUPPORT SWIMMING POOL PROJECT |
| MAKE A WISH FOUNDATION NEBRASKA | ||||||||
| 8 WEST 56TH STREET STE B-2 NORTH | KEARNEY | NE | 68847 | 470671096 | 501(C)(3) | $15,000 | $0 | MAKE A WISH PLEDGE FOR A COMMUNITY CHILD |
| CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | ||||||||
| 1000 POLE CREEK CROSSING | SIDNEY | NE | 69162 | 470686476 | 501(C)(3) | $9,000 | $0 | SPONSORSHIP OF FUNDRAISING ACTIVITIES |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 3 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | Yes (1) | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (8 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CLINTON DORWART MD | ||||||||||||||
| MEMBER - CHIEF OF MEDICAL STAFF | $181,009 | $0 | $0 | $0 | $2,328 | $0 | $8,521 | $0 | $0 | $0 | $191,858 | $0 | $0 | $0 |
| MANDY SHAW MD | ||||||||||||||
| MEMBER - PHYSICIAN AT LARGE | $334,165 | $0 | $0 | $0 | $194 | $0 | $10,260 | $0 | $0 | $0 | $344,619 | $0 | $0 | $0 |
| KELLY UTLEY | ||||||||||||||
| CFO | $153,521 | $0 | $0 | $0 | $282 | $0 | $8,006 | $0 | $27,712 | $0 | $189,521 | $0 | $0 | $0 |
| REBECCA L ALLARD MD | ||||||||||||||
| DOCTOR | $357,264 | $0 | $0 | $0 | $254 | $0 | $13,250 | $0 | $39,894 | $0 | $410,662 | $0 | $0 | $0 |
| JAMES THAYER MD | ||||||||||||||
| DOCTOR | $272,264 | $0 | $64,659 | $0 | $1,663 | $0 | $8,680 | $0 | $27,712 | $0 | $374,978 | $0 | $0 | $0 |
| MICHAEL L MATTHEWS MD | ||||||||||||||
| DOCTOR | $303,979 | $0 | $0 | $0 | $921 | $0 | $12,024 | $0 | $0 | $0 | $316,924 | $0 | $0 | $0 |
| DAVID MANKE | ||||||||||||||
| CRNA | $267,369 | $0 | $0 | $0 | $138 | $0 | $6,282 | $0 | $39,894 | $0 | $313,683 | $0 | $0 | $0 |
| JENNIFER BROWN MD | ||||||||||||||
| DOCTOR | $254,304 | $0 | $0 | $0 | $189 | $0 | $0 | $0 | $32,400 | $0 | $286,893 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 5 | DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALY, HE HAS THE OPPORTUNITY TO EARN A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. |
| SCHEDULE J, PART III: | JASON PETIK, CEO, RECEIVES COMPENSATION FROM THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, AN UNRELATED ENTITY. THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED A SALARY OF $201,518, RETIREMENT BENEFITS OF $7,347, AND NONTAXABLE BENEFITS OF $10,017. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp (2 entries)
| Bond ReferenceBondReferenceCd | Bond Issuer EINBondIssuerEIN | CUSIPCUSIPNum | Bond IssuedBondIssuedDt | Issue PriceIssuePriceAmt | PurposePurposeDesc | DefeasedDefeasedInd | On Behalf Of IssuerOnBehalfOfIssuerInd | Pool FinancingPoolFinancingInd |
|---|---|---|---|---|---|---|---|---|
| THE COUNTY OF DEUEL NEBRASKA | ||||||||
| A | 476006452 | 251476AA5 | 2014-10-16 | $10,000,000 | CONSTRUCT HOSPITAL | 0 | 0 | 0 |
| THE COUNTY OF CHEYENNE NEBRASKA | ||||||||
| B | 476006443 | 1668ATAA7 | 2014-09-30 | $32,000,000 | CONSTRUCT HOSPITAL | 0 | 0 | 0 |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp (2 entries)
| Bond ReferenceBondReferenceCd | Total ProceedsTotalProceedsAmt | Capital ExpendituresCapitalExpendituresAmt | UnspentUnspentAmt | Substantial CompletionSubstantialCompletionYr | Current RefundingCurrentRefundingInd | Advance RefundingAdvanceRefundingInd | Final Allocation MadeFinalAllocationMadeInd | Adequate Books And Rec MaintAdequateBooksAndRecMaintInd | Capitalized InterestCapitalizedInterestAmt |
|---|---|---|---|---|---|---|---|---|---|
| A | $7,192,417 | $7,142,416 | $50,001 | 2015 | 0 | 0 | 0 | Yes (1) | |
| B | $32,000,056 | $31,787,552 | $42,032 | 2015 | 0 | 0 | 0 | Yes (1) | $170,472 |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp (2 entries)
| Bond ReferenceBondReferenceCd | Owning Bond Financed PropertyOwningBondFinancedPropertyInd | Any Lease ArrangementsAnyLeaseArrangementsInd | Mgmt Contract Bond Fincd PropMgmtContractBondFincdPropInd | Any Research AgreementsAnyResearchAgreementsInd | Private Bus Use By OthersPrivateBusUseByOthersPct | Private Bus Concerning UBIPrivateBusConcerningUBIPct | Total Private Business UseTotalPrivateBusinessUsePct | Bond Iss Meet Prvt Sec Pymt TestBondIssMeetPrvtSecPymtTestInd | Change In Use Bond Financed PropChangeInUseBondFinancedPropInd | Procs Nonqualified Bond RemdtdProcsNonqualifiedBondRemdtdInd |
|---|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 0 | 0 | 0 | 0.00000 | 0.00000 | 0.00000 | 0 | 0 | Yes (1) |
| B | 0 | 0 | 0 | 0 | 0.00000 | 0.00000 | 0.00000 | 0 | 0 | Yes (1) |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp (2 entries)
| Bond ReferenceBondReferenceCd | Form8038 T FiledForm8038TFiledInd | Rebate Not Due YetRebateNotDueYetInd | Exception To RebateExceptionToRebateInd | No Rebate DueNoRebateDueInd | Variable Rate IssueVariableRateIssueInd | Hedge Identified In Bks And RecHedgeIdentifiedInBksAndRecInd | Gross Proceeds Invested In GICGrossProceedsInvestedInGICInd | Gross Proceeds InvestedGrossProceedsInvestedInd | Written Proc To Monitor ReqsWrittenProcToMonitorReqsInd |
|---|---|---|---|---|---|---|---|---|---|
| A | 0 | Yes (1) | 0 | 0 | Yes (1) | 0 | 0 | 0 | Yes (1) |
| B | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | 0 | 0 | Yes (1) |
Procedures Corrective Action ProceduresCorrectiveActionGrp (2 entries)
| Bond ReferenceBondReferenceCd | Procedures Corrective ActionProceduresCorrectiveActionInd |
|---|---|
| A | Yes (1) |
| B | Yes (1) |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | FORM 990, SCHEDULE K, PART VI: | FormAndLineReferenceDesc |
| Explanation | PART 2, LINE 3, COLUMN A - THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART 1, COLUMN (E) AS THIS DEBT WAS ISSUED ON A DRAW-DOWN BASIS AND THE TOTAL PRINCIPAL AVAILABLE HAS NOT YET BEEN DRAWN. PART 2, LINE 3, COLUMN B - THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART 1, COLUMN (E) DUE TO INVESTMENT EARNINGS. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| KEVIN UTLEY | |||
| EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO | $70,137 | EMPLOYEE COMPENSATION | 0 |
| (no name) | |||
| 0 | |||
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. EACH MONTH, SRMC PROVIDES THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY FOR COMPARISON DATA PURPOSES. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. |
| FORM 990, PART VII, SECTION A, LINE 5: | JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. |
| FORM 990, PART VII, SECTION A, LINE 1A: | MANDY SHAW, MD AND CLINTON DORWART, MD ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE COMPENSATED FOR THE MEDICAL SERVICES THEY PROVIDE. NEITHER IS PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS. |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 2,208,749. MANAGEMENT AND GENERAL EXPENSES 86,960. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,295,709. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 2,306,402. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,306,402. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 147,774. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 147,774. RECRUITING FEES: PROGRAM SERVICE EXPENSES 486,920. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 486,920. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 521,067. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 521,067. |
| FORM 990, PART XI, LINE 9: | IMPAIRMENT LOSS ON ASSETS -3,709,937. |
| FORM 990, PART XI, LINE 2C: | THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470686476 | EIN |
| Primary Activities | SUPPORT SIDNEY REGIONAL MEDICAL CENTER | PrimaryActivitiesTxt |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 11C, III-FI | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (1) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |