2016-05-11T16:13:01-05:00 2015-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2014-07-01 480559088 Hays Medical Center Inc HAYS 7856235000 2220 Canterbury Drive Hays KS 67601 John Jeter MD CEO 7856235000 2016-05-04 1 Heather R Eichem P01515553 7852334226 2016-05-04 2014 2016-08-17 19:52:53Z John Jeter MD 2220 Canterbury Drive Hays KS 67601 192049705 0 X www.haysmed.com X 1944 KS Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 16 11 1625 196 17847 0 1766093 2130293 185509035 187242012 5348353 2887936 252636 -245346 192876117 192014895 0 0 0 0 98444246 98323585 0 0 0 86310380 82934628 184754626 181258213 8121491 10756682 262539752 271006181 81603570 81736809 180936182 189269372 X Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 0 0 149429067 188088819 Patient Care Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as defined in Section 501(c)(3) of the IRS code. Admissions: Acute-5,098, Newborn ICU-41, Newborn-717, Skilled-177, Total admissions-6,033. Patient days: ICU/CPCU-6,736, Medical/Surgical-12,475, Obstetrics-1,504, Skilled-2,020, Newborn ICU-334, Newborn-1,318, Total patient days-24,387. Other statistical information: Surgical procedures-8,413, Cardiac caths-1,283, Emergency room visits-13,337, Outpatient procedures-151,264, Medical oncology service visits-6,937, Clinic visits-135,144. 149429067 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 157 0 1 1625 1 1 1 0 0 0 0 0 0 0 0 0 X 16 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X George Harms CFO 7856235000 2220 Canterbury Drive Hays KS 67601 Kenneth Beran Chair 0.50 X X 0 0 0 Alan Moore Secretary 0.50 X X 0 0 0 Jayne Clarke Treasurer 0.50 X X 0 0 0 Daniel Schippers Board Member 0.50 X 0 0 0 Dennis Bieker Board Member 0.50 X 0 0 0 Darrell Werth MD Physician/Board Member 40.00 X 600000 0 32710 Nancy Curtis Board Member 0.50 X 0 0 0 Deanna Doerfler Board Member 0.50 X 0 0 0 Jim Black DO Board Member 0.50 X 0 0 0 Mary Martin Board Member 0.50 X 0 0 0 Brian Lang Board Member 0.50 X 0 0 0 Lee Hodny MD Physician/Board Member 40.00 X 677764 0 41650 Sharon Dreher Board Member 0.50 X 0 0 0 DG Bickle Board Member 0.50 X 0 0 0 Dr Kurt Rider Physician/Board Member 40.00 X 311495 0 41650 John Jeter MD President & CEO 36.00 4.00 X X 521550 0 134596 George Harms CFO 36.00 4.00 X 156923 0 40863 Shae Veach VP Regional Dev 36.00 4.00 X 200871 0 60537 D Bruce Whittington VP Human Resources 40.00 X 170466 0 53766 Bryce Young Chief Operating Officer 36.00 4.00 X 260247 0 80480 Terry Siek Chief Nursing Officer 40.00 X 175387 0 45702 Larry Watts Chief Medical Officer 36.00 4.00 X 306053 0 77354 Alex De Carvalho Physician 40.00 X 982371 0 30195 Vivek Sharma Physician 40.00 X 940500 0 39150 Gulraiz Cheema Physician 40.00 X 833774 0 39150 Sukchan Lee Physician 40.00 X 791203 0 17111 Elizabeth Ashworth Physician 40.00 X 708998 0 30195 William Overbey Former Chief Financial Officer 40.00 X 208910 0 8410 Dale Montgomery Former VP Facilities 40.00 X 149774 0 20960 7996286 0 794479 117 1 1 0 Quest Diagnostics Inc PO Box 14730 St Louis MO 631504730 Lab Services 3622765 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Physician Coverage 1679438 Anesthesiologist Assoc of Hays PO Box 821 Hays KS 67601 Anesthesia Services 1379065 Sovereign Medical Corporation 1582 Charlton Road San Marino CA 91108 Pulmonology Services 1188300 Medassets PO Box 405652 Atlanta GA 303845652 Purchased Services 1086630 40 2079719 6627 43947 2130293 Net patient service revenue 621990 177659905 177659905 Services to CAH network and afill 900099 4038476 4038476 Fitness center 900099 1659446 1659446 Retail pharmacy 900099 1278136 1278136 EHR incentive payments 900099 469153 469153 2136896 2136896 187242012 2921490 2921490 288343 0 288343 288343 288343 1256 34810 -33554 -33554 -33554 Cafeteria revenue 722210 558464 558464 Income from purchase group partne 900099 15815 15815 Nursing mother's resources 900099 2032 2032 -1110000 -1110000 -533689 192014895 188088819 17847 1777936 4116595 1673300 2443295 77353651 64806859 12546792 2778301 2584226 194075 9178685 7644514 1534171 4896353 4020175 876178 2028496 2028496 536945 536945 197319 197319 16779987 13513542 3266445 341223 8204 333019 505253 354808 150445 2229542 1350817 878725 2081905 1691609 390296 405019 345917 59102 907175 612704 294471 2713795 2713795 11708255 8627813 3080442 1168160 928807 239353 Medical Supplies 17806063 17806063 Pharmaceuticals 13083704 13083704 Repairs and maintenance 3744543 3215931 528612 Taxes and assessments 1570386 1449787 120599 5126858 2996492 2130366 181258213 149429067 31829146 0 193815 328814 6840012 24240943 28762873 25612463 4265572 4473358 3701097 4265761 213352744 133746810 84615908 79605934 75855620 77964201 27268674 40122242 538200 538200 30497981 13854265 262539752 271006181 22682731 25095733 63545 75534 57750650 55464382 1106644 1101160 81603570 81736809 X 172165751 181326923 8770431 7942449 180936182 189269372 262539752 271006181 X 10756682 -1595510 -827982 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 18524 0 0 0 18524 0 Part II-B, Line 1: Hays Medical Center, Inc., is a member of the Kansas Hospital Association and the American Hospital Association. Both of these organizations engage in lobbying activities for hospital and general health care interests as part of the services provided to members. 10377772 11158 324882 72073 10641739 9933230 154338 335088 44884 10377772 9480780 106926 388512 42988 9933230 8947679 167515 427208 61622 9480780 8608848 119796 287574 68539 8947679 0.58790 0.32480 0.08730 0 1 1 350356 350356 76225903 40348547 35877356 125280781 86154253 39126528 11495704 7244010 4251694 79605934 6154941 F Hedge funds 18293933 F Private equity funds 5078232 F Real estate limited partnership 5722851 F Energy limited partnership 4872285 F 40122242 Interest receivable whose use is limited by Board or indenture agreement 71538 Beneficial interest in net assets of foundations 7942449 Other receivables 2157922 Debt issue costs 568041 Estimated third party payor settlements 2570510 Intercompany receivables 543805 13854265 Estimated third-party payor settlements 1101160 1101160 X 189624957 -1595510 -827982 -2423492 192048449 -33554 -33554 192014895 181291767 33554 33554 181258213 0 181258213 Part V, Line 4: The endowed funds held by the Hays Medical Center Foundation are used to help meet both the immediate and long range health care needs of patients of Hays Medical Center, Inc. The Hays Medical Center Foundation provides grants and assistance to Hays Medical Center, Inc., for property and equipment acquisitions, education, and community health issues. Part X, Line 2: Management is not aware of any uncertainties in income tax positions. Part XI, Line 2d - Other Adjustments: Change in beneficial interest in net assets of foundations Part XI, Line 4b - Other Adjustments: Loss on disposal of equipment 1 1 X 1 X 130.000000000000 1 X 1 1 0 1 1 984495 984495 0.00540 8982077 6387252 2594825 0.01430 9966572 6387252 3579320 0.01970 1779167 1676898 102269 0.00060 872530 96652 775878 0.00430 59001654 43768877 15232777 0.08400 992 992 0.00000 61654343 45542427 16111916 0.08890 71620915 51929679 19691236 0.10860 82500 82500 0.00050 82500 82500 0.00050 1 3208635 224604 57696045 58760760 -1064715 X 1 1 2 1 Hays Medical Center Inc 2220 Canterbury Hays KS 67601 X X X 2 Pawnee Valley Community Hospital Inc 923 Carroll Ave Larned KS 67550 X X X X Hays Medical Center Inc 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X http://www.haysmed.com/ X 1 14 0 1 0 1 X 130.000000000000 400.000000000000 X X X 1 1 X X X 1 X http://www.haysmed.com X http://www.haysmed.com X http://www.haysmed.com X X X X X 1 X 0 X X X X 1 X 0 0 Pawnee Valley Community Hospital Inc 2 0 0 1 X X X X X X X X X 14 1 0 1 1 X htts://www.pawneevalleyhospital.com/ X http://www.pawneecountykansas.com/ X 1 14 0 1 0 1 X 130.000000000000 400.000000000000 X X X 1 1 X X X 1 X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X X X X X 1 X 0 X X X X 1 X 0 0 Hays Medical Center, Inc. Part V, Section B, Line 5: The CHNA conducted in collaboration with the Ellis County Health Department identified significant health needs within the Ellis County and Hays Medical Center community. A town hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meetings, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees and community members were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and scoring processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interest of the community served by the Hospital. Key stakeholders in attendance included representatives from: Ellis County Health Department, Ellis County EMS, United Way of Ellis County, First Care Clinic FQHC, Regional Prevention Center, Turning Point Behavioral Health, Early Childhood Connections, USD 489 School District, Ellis County Coalition for Economic Development, North Central Kansas Technical School, Via Christi Village Retirement Center, City of Hays, and Hays Medical Center. The CHNA was coordinated and produced by VVV Research and Development, Inc., from Olathe, Kansas. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 5: The CHNA was conducted in collaboration with the Pawnee County Health Department. A Town Hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meeting, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and score processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the hospital. Key stakeholders in attendance included representatives from: United Way, Welcome Inn Senior Center, Center for Counseling, Angels Care Home Health, Golden Belt Foundation, Larned City Council, Burdett City Council and Garfield City Council and Rozel Community, Pawnee County Sherriff's office, Larned Police Department, Pawnee County Health Department, County Commissioners, members of the Chamber of Commerce, members of the USD 495 School Board, school nurses of USD 495, local members of the media, local religious organizations and representative of Pawnee Valley Community Hospital. The CHNA was coordinated and produced by VVV Research & Development, Inc. from Olathe, Kansas. Hays Medical Center, Inc. Part V, Section B, Line 6b: Ellis County, KS Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 6b: Pawnee County, KS Hays Medical Center, Inc. Part V, Section B, Line 11: HaysMed is dedicated to continually learning, engaging, and fulfilling the health needs of the community we serve. As a result of this commitment the following is the description of the actions taken during the most recent fiscal year to address the significant health needs identified through the CHNA.Add Primary Care Services - HaysMed continues to recruit physicians and advanced primary providers to the community. We have been able to hire an additional physician at HaysMed Family Practice and also added another physician to HaysMed Specialists clinic. The Convenient Care Clinic continues to be utilized with great enthusiasm by the community and maintains robust hours including weekends. Substance Abuse - HaysMed in collaboration with other community partners goal is to reduce substance abuse among target populations through early detection and intervention. We have been able to develop a system of care to address substance abuse and support collaborating agencies that address substance use issues through primary care and other medical services for jointly served patients. Tobacco cessation is a focus organization wide by implementing standardized questions for primary care practices for follow up. A community wide ad campaign was developed in collaboration with other partners to provide education and awareness of the problem. Increase Senior Care (Skilled Care) Options- HaysMed recently opened a skilled care unit consisting of 12 private licensed beds to help alleviate the need in the community. We also work closely with surrounding Critical Access Hospitals in the region and their Skilled Swing Bed units to ensure the community continues to have the skilled care options available when they need it. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 11: Annual description of the actions taken by the Hospital during the fiscal year to address the significant health needs identified throught the most recently conducted CHNA:Build and/or develop Exercise Facilities was #1 on the health needs Priorities- with 37 votes, 22.8%. Pawnee Valley Community Hospital supported USD #495 in 2015 to pass a bond for a new elementary school and renovations to the high school. Because of the CHNA and the school districts involvement and listening to the needs of Pawnee County, they have incorporated an exercise facility, in the renovations to the high school, which will be open to the public. PVCH once again had their annual fun run in June 2015. LA Psycle, opened its doors in 2015 for the community to sign up for spin classes. Pride Committee also added a second walking trail to the community. This walking trail goes around Camp Pawnee. PVCH staff have done community presentations for heart disease awareness. Expand Oncology Treatment was #2 on the health needs priorities - with 25 votes, 15.4%. In order to implement an effective oncology service line, many factors must come together. We have explored the feasibility of offering oncology services and providers in Pawnee County and it was determined not to be feasible at this time. We have had the great fortune of being able to partner with the Dreiling/Schmidt Cancer Institute at HaysMed. In lieu of this partnership, we hope to continue to be an outreach clinic for Dreiling/Schmidt Cancer Institute. It is vitally important to maintain the relationship with both primary care medical staff as well as specialists. This will ensure consistent continuity for our patients as they move through the continuum of their cancer treatment course. Improve Quality Air Flow was #3 on health needs priorities - with 20 votes, 12.3%. We plan to continue to look into improving air quality in Pawnee County. More research needs to be done to determine if it is feasible for PVCH to implement a plan to address air quality issues. Reducing Drug/Alcohol Abuse was #4 on health needs priorities - with 20 votes, 12.3%. The Pawnee County Health Department in coordination with the Center For Counseling & Consultation has received a grant for improving health in rural communities from the Centene Foundation. As part of this grant opportunity, we are working with Wichita State University's Community Engagement Institute to administer a behavioral health survey to identified community partners/stakeholders in Pawnee, Barton, Rice and Stafford Counties. The survey is designed to bring a better understanding of current awareness and support for community based mental health and substance abuse services. While the survey's primary purpose is to identify demand for specific behavioral health services, areas for improvement, and past utilization/referrals, the survey will also serve a primary role in starting conversations for change and greater community involvement in each of these counties. We hope to increase the recognition and understanding of the importance of mental health and substance abuse issues in our county. Provide Healthy Food Options was #5 on health needs priorities - with 14 votes, 8.6%. Pawnee Valley Community Hospital is promoting healthy eating lifestyles focusing on food labels, healthy meal options, nutrition, and portion control. There are no vending machines in our hospital and candy bars and sweet snacks have been eliminated from the grab and go section of the cafeteria. We continue to offer diabetic education classes and have increased the class to a two day session. Participants eat at the facility and go through the cafeteria line and are encouraged to make healthier food choices. PVCH continues to educate children at their annual sixth grade health fair and includes education on portion control, label reading, and exercise. PVCH and Pawnee County Health Department have both had educational booths at the county fair and twice a year at the community health fair. The health department has increased their educational items pertaining to healthy food options for the public to obtain. Increase Access to Home Health/Hospice was #6 on health needs priorities with 11 votes, 6.8%. Continuing to look at the feasibility and what we can do to increase access to home health/hospice. We will continue to promote existing agencies and educate patients of services available. PVCH has partnered with the Kansas Heart and Stroke Collaborative and have a part time staff member that goes into the home and checks on the patient and makes sure they are following the guidelines provided by their physician, pertaining to heart and stroke. Offer Nursing Home - Dementia Services was #7 on health needs priorities with 11 votes, 6.8%. Country Living Assisted Living facility in Pawnee County recently opened a building specifically for dementia patients. We will continue to work on identifying nursing home dementia services in Pawnee County and educate entities and individuals who may be in need of these services. Hays Medical Center, Inc. Part V, Section B, Line 22d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 22d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Hays Medical Center, Inc. Part V, Section B, line 16a website: http://www.haysmed.com Hays Medical Center, Inc. Part V, Section B, line 16b website: http://www.haysmed.com Hays Medical Center, Inc. Part V, Section B, line 16c website: http://www.haysmed.com Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16a website: http://http://www.pawneevalleyhospital.com/ Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16b website: http://http://www.pawneevalleyhospital.com/ Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16c website: http://http://www.pawneevalleyhospital.com/ 4 St Rose Health Center LLC 3515 Broadway Great Bend KS 67530 Primary care services Hays Family Medicine 2509 Canterbury Hays KS 67601 Family medicine HaysMed Convenient Care Walk-in Clinic 2501 E 13th St Hays KS 67601 Convenient care services HaysMed Psychiatric Associates 205 E 7th St Hays KS 67601 Psychiatric services Part I, Line 7: Hays Medical Center, Inc.'s, cost accounting system was used to calculate community health improvement services, health professions education, and subsidized health services costs. A cost-to-charge ratio derived from Worksheet 2 was used to calculate financial assistance at cost and the community benefit expense attributable to serving Medicaid beneficiaries. Part I, Line 7g: Subsidized health services community benefit expenses include $53,263,694 of expenses attributable to physician clinics that have net operating losses. Part II, Community Building Activities: Hays Medical Center, Inc., helps to support the First Care Clinic in Hays, Kansas. This clinic was established to help lower income individuals receive health care at a reduced cost. Our support helps to increase the number of individuals in Hays, Kansas, who receive quality primary health care. Part III, Line 4: Text of the footnote that describes bad debt expense:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the HaysMed Group analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the HaysMed Group analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the HaysMed Group 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 uncollectible accounts.Part III, Line 2:Costing methodology: A cost-to-charge ratio derived from Worksheet 2 was used to calculate bad debt expense at cost.Part III, Line 3:Methodology for bad debt cost for financial assistance eligible: This amount was estimated based on historical information from our collection agency on the percentage of accounts referred to collection whose guarantor was indigent. Part III, Line 8: The Medicare cost report was the costing methodology used to determine Medicare allowable costs. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Hays Medical Center, Inc., Medicare cost report for the fiscal year ended June 30, 2015. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Hays Medical Center, Inc., try to determine the estimated self-pay balance prior to the patient receiving services. FAP eligibility is first considered at this point in time. In addition, if full payment is not received or if payment is not made within 30 days, the CSR contacts the patient. If it is determined that at least a 2-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Part VI, Line 3: Information regarding the Hays Medical Center, Inc., charity care program is located on the Hays Medical Center, Inc., website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative of Hays Medical Center, Inc., contacts a patient about a bill and in visiting with them they determine that the patient could possibly qualify for the Hospital's charity care policy, they will send the application to the patient as well. Part VI, Line 4: Hays Medical Center, Inc., is located in Hays, Kansas, which has a population of approximately 21,000 people as of the 2014 per the U.S. Census Bureau. One of the State of Kansas Regents universities is also located in Hays, Kansas, so the population includes many college-aged students. The median household income of Hays, Kansas, is approximately $42,000. Approximately 18.8% of the population was below the poverty line. Almost 6% of the Hospital's revenue is from services provided to patients eligible for Medicaid. Hays Medical Center, Inc., is the only hospital in the city of Hays. In addition, since this is a rural area and because it is the only hospital providing tertiary level care in the region, Hays Medical Center, Inc., provides certain services to the whole western half of the State of Kansas. Part VI, Line 5: Hays Medical Center, Inc., promotes the health of the community by extending medical privileges to most qualified, local physicians. In addition, the majority of the Board of Directors live and work in the city of Hays, but they are not employed by Hays Medical Center, Inc. Part VI, Line 6: Hays Medical Center, Inc., is not a part of an affiliated health care system. X 1 1 X X X X 1 1 0 0 0 1 0 0 0 Darrell Werth MD Physician/Board Member 600000 0 0 0 0 0 15600 0 17110 0 632710 0 0 0 Lee Hodny MD Physician/Board Member 347500 0 320764 0 9500 0 15600 0 26050 0 719414 0 0 0 Dr Kurt Rider Physician/Board Member 297500 0 0 0 13995 0 15600 0 26050 0 353145 0 0 0 John Jeter MD President & CEO 519639 0 0 0 1911 0 111046 0 23550 0 656146 0 0 0 George Harms CFO 156923 0 0 0 0 0 23538 0 17325 0 197786 0 0 0 Shae Veach VP Regional Dev 163194 0 0 0 37677 0 36741 0 23796 0 261408 0 0 0 D Bruce Whittington VP Human Resources 157547 0 0 0 12919 0 28970 0 24796 0 224232 0 0 0 Bryce Young Chief Operating Officer 257922 0 0 0 2325 0 54663 0 25817 0 340727 0 0 0 Terry Siek Chief Nursing Officer 174577 0 0 0 810 0 36710 0 8992 0 221089 0 0 0 Larry Watts Chief Medical Officer 299172 0 0 0 6881 0 60476 0 16878 0 383407 0 0 0 Alex De Carvalho Physician 550000 0 432371 0 0 0 15600 0 14595 0 1012566 0 0 0 Vivek Sharma Physician 500000 0 440500 0 0 0 15600 0 23550 0 979650 0 0 0 Gulraiz Cheema Physician 505769 0 328005 0 0 0 15600 0 23550 0 872924 0 0 0 Sukchan Lee Physician 500000 0 290340 0 863 0 0 0 17111 0 808314 0 0 0 Elizabeth Ashworth Physician 540000 0 0 0 168998 0 15600 0 14595 0 739193 0 0 0 William Overbey Former Chief Financial Officer 17868 0 0 0 191042 0 5167 0 3243 0 217320 0 0 0 Dale Montgomery Former VP Facilities 80365 0 0 0 69409 0 18224 0 2736 0 170734 0 0 0 Part I, Line 1a Benefits identified include tax indemnification on health claims. This benefit is available to the CEO and is included in taxable income. Part I, Lines 4a-b Severance payments: Dale Montgomery - $69,409 William Overbey - $191,042 Contributions to plan: John Jeter, M.D. - $77,246 George Harms - $23,538 Bryce Young - $39,063 D. Bruce Whittington - $23,932 Shae Veach - $24,629 Terry Siek - $26,187 Larry Watts - $44,876 Part I, Line 6 A portion of incentive compensation for officers and key employees is determined by net earnings exceeding budget for the fiscal year. A Kansas Development Finance Authority 481066589 48543BJD1 2005-11-22 23635944 Construction 0 0 0 B Kansas Development Finance Authority 481066589 48543BLY2 2010-11-02 46930167 Refinancing of previous bond and equipment 0 0 0 A 9820000 23635944 2037125 316000 23319944 2006 0 1 1 1 B 4470000 46930167 667574 29962593 16300000 2012 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: Kansas Development Finance Authority Date the Rebate Computation was Performed: 11/01/2014 Ann Jeter Family member of John Jeter, CEO 10290 Payments for consulting services 0 Jeter Law Firm Partnership more than 5% owned by family member of John Jeter, CEO 4386 Payments for legal services 0 Lynette Pfannenstiel Family member of D.G. Bickle, current director 98414 Employment 0 Arlene Werth Family member of Darrell Werth, MD, current director 67254 Employment 0 Chase Young Family member of Bryce Young, COO 12364 Employment 0 Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the officers and Board Finance committee. Form 990, Part VI, Section B, line 12c Officers, directors, and key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The CEO's, officers', and key employees' salaries are reviewed annually by an independent consulting group and the Compensation Committee, which is made up of members of the Board. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Financial statements are released to bond holders on a quarterly basis. Form 990, Part XI, line 9: Change in beneficial interest in net assets of foundations -827,982. Hays Medical Center Foundation 2220 Canterbury Hays KS 67601 481179684 Provide grants and allocations to Hays Medical Center, Inc. KS 501(c)(3) Line 11a, I Hays Medical Center Inc 1 HaysMed Partners Inc 2220 Canterbury Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) Line 3 Hays Medical Center Inc 1 Pawnee Valley Community Hospital Inc 2220 Canterbury Hays KS 67601 481253246 Hospital operated by Hays Medical Center KS 501(c)(3) Line 3 HaysMed Partners Inc 1 Hadley Foundation Inc 1200 Main Hays KS 67601 481107034 Support for Hays Medical Center KS 501(c)(3) Line 11c, III-FI 0 0 0 1 1 1 0 0 0 0 1 0 1 1 1 1 0 1 0 0 Hays Medical Center Foundation C 2079719 Actual cash Hays Medical Center Foundation Q 238576 Actual cost Pawnee Valley Community Hospital Inc L 520038 Actual cost Pawnee Valley Community Hospital Inc O 414833 Actual cost Pawnee Valley Community Hospital Inc Q 2340000 Contractual formula Pawnee Valley Community Hospital Inc D 369470 Actual cost