2016-05-16T13:29:09-05:00 2015-06-30 461497033 EKS&H LLLP 7979 E TUFTS AVENUE SUITE 400 DENVER CO 802372521 990 2014-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 9702377000 2016-05-13 1 DORI J EGGETT P00645252 3037409400 2014 2016-08-17 19:52:53Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 512813222 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES THROUGH LEARNING, HEALING, DISCOVERY, AND THROUGH HUMAN CONNECTION. 11 9 4255 600 4645969 3061887 4199637 2220807 446107775 471312432 15060636 23773424 12929131 10670778 478297179 507977441 36808195 31381120 0 0 186655969 185330975 0 0 0 216747452 205327882 440211616 422039977 38085563 85937464 1439397024 2242473093 687341243 1327312245 752055781 915160848 WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 0 384072441 31381120 471145859 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2015, PVHC RECORDED 59,798 PATIENT DAYS, 15,358 ADMISSIONS, 223,571 OUTPATIENT VISITS, 58,589 EMERGENCY VISITS, 2,297 DELIVERIES, 4,502 INPATIENT SURGERIES, AND 4,987 OUTPATIENT SURGERIES. 384072441 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 1 0 0 1 265 0 1 4255 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X STEPHANIE DOUGHTY 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 CHRISTINE CHIN BOARD CHAIR 1.00 2.00 X X 0 0 0 MIKE DELLENBACH VICE BOARD CHAIR 1.00 2.00 X X 0 0 0 DENNIS HOUSKA BOARD MEMBER 1.00 2.00 X 0 0 0 THAINE MICHIE BOARD MEMBER 1.00 2.00 X 0 0 0 CHRIS OSBORN BOARD MEMBER 1.00 2.00 X 0 0 0 JOHN MENTEN BOARD MEMBER 1.00 2.00 X 0 0 0 JAMES SPROWELL MD BOARD MEMBER 1.00 2.00 X 0 0 0 LAURIE STEELE BOARD MEMBER 1.00 2.00 X 0 0 0 DAN STROH BOARD MEMBER 1.00 2.00 X 0 0 0 STEVE THORSON MD BOARD MEMBER 1.00 2.00 X 0 0 0 KEVIN UNGER PRESIDENT/CEO 25.00 25.00 X X 538803 538803 108353 STEPHANIE DOUGHTY CFO 25.00 25.00 X 293273 293273 61859 DONNA PODUSKA CNO 50.00 X 235278 0 33364 MICHAEL RANDLE CMO, CHMG 50.00 X 369807 0 54037 STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 40.00 X 399640 0 52039 KENNETH WATANABE PSYCHIATRIST 40.00 X 268454 0 46452 JANELL WOZNIAK PHYSICIAN-RESIDENCY PGRM DIRECTOR 40.00 X 269788 0 45828 JOSEPH GOTTFRIED PSYCHIATRIST 40.00 X 258080 0 47667 DANNY ROBINSON CEO, CHMG 25.00 25.00 X 215053 198520 58081 STEVEN SCHWARTZ CFO, CHMG 25.00 25.00 X 94617 124677 37248 2942793 1155273 544928 105 1 1 0 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY RD 300 FT COLLINS CO 80528 MEDICAL 2123439 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE 300 FT COLLINS CO 80524 MEDICAL 1697678 ALLIED BARTON SECURITY 161 WASHINGTON ST 600 CONSHOHOCKEN PA 19428 SECURITY 1691419 SUMMIT PATHOLOGY 5802 WRIGHT DR LOVELAND CO 80538 MEDICAL 1368374 FORT COLLINS YOUTH CLINIC 1214 OAK PARK DR FORT COLLINS CO 80525 MEDICAL 1315833 47 1572744 374771 273292 1486876 2220807 NET PATIENT SVC REV 900099 472344142 472344142 PROVIDER FEE INCOME 621400 28906490 28906490 DIETARY SVC INCOME 900099 2088151 2088151 JOINT VENTURE 621400 -32303826 -32948229 644403 277475 252116 25359 471312432 11081537 11081537 880994 880994 9444483 123404 1987551 123404 7456932 0 7456932 3452131 4004801 7105547 7146673 0 2441327 7105547 4705346 11810893 11810893 381521 283499 98022 98022 MISCELLANEOUS REVENUE 621400 2054043 1529967 524076 EHR REVENUE 624100 1061373 1061373 INCOME TAX REFUND 621400 408 408 3115824 507977441 471145859 4645969 29964806 31381120 31381120 1300678 383497 917181 65727 65727 141932975 128797885 13135090 23357875 21142024 2215851 16803450 15911454 891996 1870270 1692846 177424 30250 30250 67051 67051 26600 26600 939162 939162 28033581 23673138 4360443 3039738 7258 3032480 4054559 3615057 439502 5847192 5108102 739090 3894293 3524859 369434 1074293 784771 289522 323351 278506 44845 9696030 9696030 22440248 17268543 5171705 1966969 127182 1839787 UBI TAXES 944998 944998 MEDICAL SUPPLIES 76833971 76742864 91107 BAD DEBT 21354240 21354240 PROVIDER FEE EXPENSE 20647416 20647416 4113940 1869922 2244018 422039977 384072441 37967536 0 3709644 68533778 1026320 1489346 56214512 50779998 1364113 45308 6500134 6998323 3427999 3617968 554669199 299827366 261849234 254841833 6123945 780602336 2997063 0 24095655 26245368 1072088405 1049318835 1439397024 2242473093 53074553 63770176 69473 59968 131401661 204385503 131854723 23496487 1379436 61245 369561397 1035538866 687341243 1327312245 X 752055781 915160848 752055781 915160848 1439397024 2242473093 X 85937464 -3658679 80826282 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 26600 0 0 26600 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 11287236 2977196 98459 1595156 1525623 11242112 10692037 4841525 985793 3756845 1455274 11287236 8938992 2680308 520466 565964 881765 10692037 8589487 1202986 379517 448977 784021 8938992 8012240 3552647 -345716 1678528 712777 238379 8589487 0.56390 0.43610 1 1 1 59951616 59951616 189616546 103943845 85672701 92100199 63372188 28728011 153624020 100998658 52625362 59376818 31512675 27864143 254841833 INTERCOMPANY RECEIVABLE 1022579823 DEFERRED DEBT ISSUANCE COSTS 3057982 OTHER RECEIVABLES 3994117 DEFERRED PENSION OUTFLOW COSTS 19686913 1049318835 INTERCOMPANY PAYABLES 1013097204 ACCRUED INTEREST PAYABLE 1355370 OTHER DEFERRED EXPENSES 2852960 PENSION LIABILITIES 18233332 1035538866 521456621 -3658679 2110955 -1547724 523004345 -15026904 -15026904 507977441 401486954 2110955 2110955 399375999 22663978 22663978 422039977 PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,110,955. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 21,354,239. AUXILIARY INCOME NOT INCLUDED IN AFS INCOME 98,022. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 225,739. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 25,359. RENTAL EXP AS INCOME ON 990 10,071. INCOME TAX REFUND REDUCED EXPENSES ON AFS 408. INVESTMENT EXPENSE REPORTED AS INCOME ON AFS 939,162. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS -37,679,904. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,110,955. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 21,354,239. AUXILIARY GRANTS NOT ON AFS 109,000. RENTAL EXP AS INCOME ON 990 10,071. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 25,359. INCOME TAX REFUND REDUCED EXPENSES ON AFS 408. CASH CONTRIBUTIONS FROM FOUNDATION NOT IN AFS REVENUE 225,739. INVESTMENT EXPENSE REPORTED AS INCOME ON AFS 939,162. 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 759922 759922 0.00180 61689920 50887549 10802371 0.02560 20652344 20567826 84518 0.00020 83102186 71455375 11646811 0.02760 2417945 177800 2240145 0.00530 5644690 1040346 4604344 0.01090 9016258 6065985 2950273 0.00700 1057678 213539 844139 0.00200 31289872 31289872 0.07410 49426443 7497670 41928773 0.09930 132528629 78953045 53575584 0.12690 200 200 0.00000 81338 81338 0.00020 1000 1000 0.00000 1245 1245 0.00000 150370 150370 0.00040 234153 234153 0.00060 1 23781564 137860111 176974237 -39114126 X 1 1 1 HARMONY SURGERY CENTER LLC AMBULATORY SURGERY 0.50000 0.50000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVICES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURGERY 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33000 0.67000 8 PVHS-ICM EHW LLC MEDICAL CLINIC 0.50000 0.50000 1 1 POUDRE VALLEY HOSPITAL 1024 S LEMAY FORT COLLINS CO 80524 X X X X X PHARMACY, LAB, CARDIOVASCULAR POUDRE VALLEY HEALTH CARE 1 0 0 1 X X X X X X X X X X 12 1 1 1 1 X SEE PART V, SECTION C X 1 12 1 SEE PART V, SECTION C 0 0 1 X 250.000000000000 400.000000000000 X X X X X 1 1 X X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X 1 X 0 X X X X 1 X 0 0 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 3J: THE CHNA REPORT ALSO DESCRIBES CLINICAL SERVICES PROVIDED BY HOSPITAL FACILITY ADDRESSING THE FOUR LEADING CAUSES OF MORTALITY IN THE COUNTY. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5: TWO COMMUNITY MEETINGS WERE HELD DURING FEBRUARY 2013 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. THE FOLLOWING INDIVIDUALS WERE CONSULTED:ANNETTE ALFANO, UNIVERSITY OF COLORADO HEALTHMARY ATCHISON, KAISER PERMANENTEKRISTIN BIERI, FOOD BANK FOR LARIMER COUNTYDEBORAH CAMPBELL, LARIMER COUNTY COMPASSJENNIFER CHASE, NORTHERN COLORADO AIDS PROJECTANDREA CLEMENT-JOHNSON, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTBRUCE COOPER, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYLORI DAIGLE, NORTHERN COLORADO AIDS PROJECTALISON DAWSON, DISABLED RESOURCE SERVICESEMILY DAWSON PETERSEN, TOUCHSTONE HEALTH PARTNERSTOM DONNELLY, LARIMER COUNTY COMMISSIONERSMICHELE DOYLE, COLUMBINE HEALTH CARE SYSTEMSLINDA FELLION, EARLY CHILDHOOD COUNCIL OF LARIMER COUNTYLEW GAITER, LARIMER COUNTY COMMISSIONERSCHAZZ GLAZE, SALUD FAMILY HEALTH CENTERNEIL GLUCKMAN, LARIMER COUNTY, ASSISTANT COUNTY MANAGERMARTHA HARGRAVES, COMMUNITY MEMBERBARBARA HARTMAN, THOMPSON SCHOOL DISTRICTSUE HEWITT, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYJESSICA HINTERBERG, CANDO WITH UNIVERSITY OF COLORADO HEALTHERICA IVERSON, FOOD BANK FOR LARIMER COUNTYSTEVE JOHNSON, LARIMER COUNTY COMMISSIONERSASHLEY KASPRZAK, TEAM FORT COLLINSKATY KOHNEN, LEAGUE OF WOMEN VOTERSJENNY LANGNESS, ALPHA CENTERJENNIFER LEE, LARIMER COUNTY BOARD OF HEALTHDIANA LINDEN, PLANNED PARENTHOOD OF THE ROCKY MOUNTAIN'S RESPONSIBLE SEX EDUCATION INSTITUTEMARIE MACPHERSON, LARIMER COUNTY DEPT OF HEALTH AND ENVIRONMENTJOHN MCGEE, CROSSROADS SAFEHOUSEDAWN NANNINI, TEAM FORT COLLINSKAREN NICHOLSON, ESTES PARK MEDICAL CENTERTRACI ODDY, BANNER MCKEE MEDICAL CENTERCAROL PLOCK, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYMARK RICHARDS, LARIMER COUNTY BOARD OF HEALTHDOUG RYAN, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTKIM SHARPE, HEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYBILL STOUT, WOMEN'S RESOURCE CENTERAVERIL STRAND, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTDEIRDRE SULLIVAN, CANDO WITH UNIVERSITY OF COLORADO HEALTHJILL TAYLOR, UNIVERSITY OF COLORADO HEALTHGRACE TAYLOR, UNIVERSITY OF COLORADO HEALTHMARILYN THAYER, COMMUNITY ORGANIZING TO REACH EMPOWERMENT (CORE) CENTERLEE THIELEN, THIELEN CONSULTINGCOLETTE THOMPSON, UNIVERSITY OF COLORADO HEALTHJANE VISTE, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTSCOTT VON BARGEN, TURNING POINT CENTER FOR YOUTH & FAMILY DEVELOPMENTMARGARET WATSON, UNITED WAY 2-1-1 OF LARIMER COUNTYNANCY WEBER, POUDRE SCHOOL DISTRICTVALERIE WENDELL, BOHEMIAN FOUNDATIONLISE YOUNGBLADE, HUMAN DEVELOPMENT AND FAMILY STUDIES/COLORADO STATE UNIVERSITYSTEVE YURASH, LARIMER COUNTY BOARD OF HEALTH POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6A: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2012 CHNA. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6B: ALPHA CENTERBOHEMIAN FOUNDATIONCOLUMBINE HEALTH CARE SYSTEMSCOMMUNITY ORGANIZING TO REACH EMPOWERMENT CENTERCROSSROADS SAFEHOUSEDISABLES RESOURCE SERVICESEARLY CHILDHOOD COUNCIL OF LARIMER COUNTYFOOD BANK FOR LARIMER COUNTYHEALTH DISTRICT OF N. LARIMER COUNTYHEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYHUMAN DEVELOMENT AND FAMILY STUDIES @ CSUKAISER PERMANENTELARIMER COUNTRY DEPARTMENT OF HEALTH AND ENVIRONMENTLARIMER COUNTYLARIMER COUNTY BOARD OF HEALTHLARIMER COUNTY COMMISSIONERSLARIMER COUNTY COMPASSLEAGUE OF WOMEN VOTERSNORTHERN COLORADO AIDS PROJECTPLANNED PARENTHOODPOUDRE SCHOOL DISTRICTSALUD FAMILY HEALTH CENTERTEAM FORT COLLINSTHIELEN CONSULTINGTHOMPSON SCHOOL DISTRICTTOUCHSTONE HEALTH PARTNERSTURNING POINT CENTER FOR YOUTH AND FAMILY DEVELOPMENTUNITED WAY OF LARIMER COUNTYWOMEN'S RESOURCE CENTERPART V, LINE 7A:WEBSITE: HTTPS://WWW.UCHEALTH.ORG/DOCUMENTS/FILE-PDF/ABOUT- CHNA-WEB201213.PDFPART V, LINE 10A: HTTPS://WWW.UCHEALTH.ORG/DOCUMENTS/FILE-PDF /ABOUT-2013-IMPLEMENTATIONSTRATEGY-UCHEALTHNORTH.PDF POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 11: AN IDENTIFIED HEALTH ISSUE RELATED TO A HIGH RATE OF UNINTENDED TEEN PREGNANCY IN WELD COUNTY IS NOT BEING ADDRESSED WITH DIRECT RESOURCES ALLOCATED FROM POUDRE VALLEY HOSPITAL OR THE MEDICAL CENTER OF THE ROCKIES. THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT PROVIDES REPRODUCTIVE HEALTH SERVICES FOR TEENS THROUGH A TITLE X CLINIC. ADDITIONAL EDUCATION AND OUTREACH TO WELD COUNTY TEENS IS PROVIDED BY A COMMUNITY ORGANIZATION; LUTHERAN FAMILY SERVICES. POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDED SUPPORT TO THIS ORGANIZATION THROUGH CASH DONATIONS TOTALING $2,460.00 DURING THE 2012/13 FISCAL YEAR AND $2,500 DURING THE 2013/14 FISCAL YEAR. ANOTHER IDENTIFIED HEALTH ISSUE - MOTOR VEHICLE SAFETY FOR TEENS IN WELD COUNTY - IS ALSO NOT BEING DIRECTLY ADDRESSED DUE TO LACK OF RESOURCES. THE ISSUE IS BEING ADDRESSED BY A NON-PROFIT COMMUNITY COALITION - DRIVE SMART WELD COUNTY - WHICH HAS DEDICATED RESOURCES AND ACTION PLANS TO ADDRESS THIS ISSUE.PART V, LINE 16:FINANCIAL ASSISTANCE POLICY: HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4 PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16A WEBSITE: SEE PART V, SECTION C POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16B WEBSITE: SEE PART V, SECTION C POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16C WEBSITE: SEE PART V, SECTION C 56 HARMONY CAMPUS MOB 2121 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICES, ONCOLOGY, HCOR, CANCER CENTER HARMONY CAMPUS AMBULATORY CARE CENTER 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE MCR NORTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES CHMG CLINICS 1400 E BOULDER STREET COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES GREELEY MEDICAL CLINIC 1900 16TH STREET GREELEY CO 80631 PHYSICIAN OFFICES,LAB, RADIOLOGY & ONCOLOGY REDSTONE 2315 E HARMONY RD FORT COLLINS CO 80528 OUTPAITENT LAB, PHYSICIAN OFFICE, UROLOGY CHMG-LONGMONT 1925 MOUNTAIN VIEW AVE LONGMONT CO 80501 PHYSICIAN OFFICES PHYSICIAN CLINICS 4110 BRIARGATE PARKWAY COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES PEAKVIEW MEDICAL CENTER 5881 W 16TH STREET GREELEY CO 80634 PHYSICIAN OFFICES, LAB & RADIOLOGY PENNOCK PLACE 1025 PENNOCK PLACE FORT COLLINS CO 80524 PHYSICIAN OFFICES, BLOOD BANK MOUNTAIN CREST BEHAVIORAL HEALTH 4601 CORBETT DR FORT COLLINS CO 80528 BEHAVORIAL HEALTH PROSPECT MEDICAL PLAZA 1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524 PHYSICIAN OFFICES, OUTPAITENT REHAB, NEUROLOGY, INT MEDICINE CENTRE AVE HEALTH AND REHAB-JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB SNOW MESA 4674 SNOW MESA DRIVE FORT COLLINS CO 80528 PHYSICIAN OFFICES CHMG CHEYENNE MEDICAL SPECIALISTS 5050 POWDERHOUSE RD CHEYENNE WY 82009 PHYSICIAN OFFICES WESTBRIDGE 1107 S LEMAY FORT COLLINS CO 80524 PHYSICIAN OFFICES, BLOOD DRAW, SLEEP LAB, WEE STEPS CHMG PHYSICIAN CLINICS 525 N FOOTE AVE SUITE 302 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES SURGERY CENTER OF FT COLLINS-JV 1100 E PROSPECT RD FORT COLLINS CO 80524 SURGERY CENTER MCR SOUTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES, HCOR, SSOR, SLEEP LAB, SURGERY CENTER WINDSOR MEDICAL CENTER 1455 MAIN STREET WINDSOR CO 80550 PHYSICIAN OFFICES, RADIOLOGY, LAB MEMORIAL NEUROSCIENCES 1725 BOULDER STREET SUITE 101 COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES UROLOGY CENTER OF THE ROCKIES 3520 E 15TH STREET LOVELAND CO 80538 PHYSICIAN OFFICES EXPRESS LAB 1020 DOCTORS LANE FORT COLLINS CO 80524 LAB CHMG OB-GYN CLINIC 1715 61ST AVENUE GREELEY CO 80631 PHYSICIAN OFFICES NORTH SPRINGS FAMILY MEDICINE & URGENT C 8540 SCARBOROUGH DRIVE COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES CHILDREN'S THERAPY 1500 S LEMAY FORT COLLINS CO 80526 THERAPY WEST LOVELAND 3850 N GRANT AVE LOVELAND CO 80538 URGENT CARE, PHYSICIAN OFFICES TIMBERLINE MEDICAL 131 STANLEY DR ESTES PARK CO 80517 PHYSICIAN OFFICES CHMG PRIMARY CARE AT BRIARGATE 8890 N UNION BLVD SUITE 100B COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES PHYSICIAN CLINICS 175 S UNION BLVD COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES COLUMBINE POUDRE HOMECARE-JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE HCORSCOTTSBLUFF 2 W 42ND ST 2200 SCOTTSBLUFF NE 69361 PHYSICIAN OFFICES CHMG PRIMARY CARE - ROCKRIMMON 6615 DELMONICO DRIVE COLORADO SPRINGS CO 80919 PHYSICIAN OFFICES MEMORIAL SUNFLOWER FAMILY MEDICINE 1730 N CORONA STREET COLORADO SPRINGS CO 80907 PHYSICIAN OFFICES PRIMARY CARE-STERLING 620 IRIS DRIVE STERLING CO 80751 PHYSICIAN OFFICES EYE LASER CENTER OF N COLORADO-JV 1725 EAST PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES CHMG-FIRESTONE 660 FIRESTONE BLVD FIRESTONE CO 80504 PHYSICIAN OFFICES THOMPSON VALLEY TOWNE CENTER 1327 EAGLE DRIVE LOVELAND CO 80537 PHYSICIAN OFFICES ORTHOPEDIC & HAND 3830 N GRANT AVE LOVELAND CO 80538 PHYSICIAN OFFICES YAMPA VALLEY STEAMBOAT 940 CENTRAL PARK DR 290 STEAMBOAT SPRINGS CO 80487 PHYSICIAN OFFICES THE VEIN AND LASER CENTER-JV 2008 CARIBOU DRIVE FORT COLLINS CO 80525 PHYSICIAN OFFICES CHMG PRIMARY CARE - NO UNION 5333 N UNION BLVD SUITE 200 COLORADO SPRINGS CO 80918 PHYSICIAN OFFICES FORT MORGAN 1000 LINCOLN STREET 207 FORT MORGAN CO 80701 PHYSICIAN OFFICES WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 OUTPATIENT REHAB LARAMIE 3116 WILLET DRIVE LARAMIE WY 82070 PHYSICIAN OFFICES ESTES PARK 555 PROSPECT AVE ESTES PARK CO 80517 PHYSICIAN OFFICES CRAIG 595 RUSSELL STREET CRAIG CO 81625 PHYSICIAN OFFICES SIDNEY 1625 DORWART DRIVE SIDNEY NE 69162 PHYSICIAN OFFICES CHMG HCOR CV SURGEON 2030 MOUNTAIN VIEW AVE 540 LONGMONT CO 80501 PHYSICIAN OFFICES PHLEBOTOMY STATION 1107 SOUTH LEMAY AVE FORT COLLINS CO 80526 LAB DRAWS PHLEBOTOMY STATION 1113 OAKRIDGE DRIVE FORT COLLINS CO 80525 LAB DRAWS PHLEBOTOMY STATION 2001 S SHIELDS FORT COLLINS CO 80526 LAB DRAWS PHLEBOTOMY STATION 2025 BIG HORN DRIVE FORT COLLINS CO 80525 LAB DRAWS PHLEBOTOMY STATION 3519 RICHMOND DRIVE FORT COLLINS CO 80526 LAB DRAWS HAYTHORN BROTHERS 7251 W 20TH ST GREELEY CO 80631 SLEEP LAB PRIMARY CARE-MONUMENT 15854 JACKSON CREEK PARKWAY SUITE 120 MONUMENT CO 80132 PHYSICIAN OFFICES PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $23,781,564. PART II, COMMUNITY BUILDING ACTIVITIES: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 87,131,659CENTER AVE COST REPORT: 3,678,552COLUMBINE HOMECARE COST REPORT: 1,200,461PVHC DISALLOWED PROGRAMS: 800,587JOINT VENTURES: 45,048,852TOTAL TO LINE 5: 137,860,111PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2015 COST REPORT AGGREGATED WITH DISREGARDED ENTITIES AND OWNERSHIP PORTIONS OF JOINT VENTURES. PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 106,716,188CENTRE AVE COST REPORT: 5,645,512COLUMBINE HOMECARE COST REPORT: 1,436,645PVHC DISALLOWED PROGRAMS: 1,089,938JOINT VENTURES: 62,085,954TOTAL TO LINE 6: 176,974,237 PART III, LINE 8: APPROXIMATELY 23.48% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART III, LINE 9B: PATIENT PROVIDES DOCUMENTATION BASED ON COLORADO INDIGENT CARE GUIDELINES, REVIEWED BY FINANCIAL ASSISTANCE COMMITTEE (FAC), CROSS FUNCTIONAL TEAM CHAIRED BY DIRECTOR PATIENT FINANCIAL SERVICES. UPON APPROVAL OR DENIAL OF THE REQUEST FOR CHARITABLE AID FROM THE FAC, THE PATIENT WILL BE ADVISED OF THE DECISION. THE BILL IS PARTIALLY OR TOTALLY ADJUSTED AS APPROVED BY THE FAC, NO FURTHER COLLECTION PROCESS WITH THE PATIENT. FOR ANY PORTION NOT ADJUSTED OFF, THE PROPER SEQUENCE OF ATTEMPTS TO COLLECT ARE FOLLOWED. FINAL ASSIGNMENT OF THE BILL IS TO A COLLECTION AGENCY. PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS). PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE EMERGENCY DEPARTMENT, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. PART VI, LINE 4: POUDRE VALLEY HEALTH CARE INC. IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTH CARE TO HEALTH. BASED IN NORTHERN COLORADO, PVHC PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVHC IS A PART OF THE UNIVERSITY OF COLORADO HEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, COLORADO HEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS AS FOLLOWS: WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS . WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. PART VI, LINE 7, REPORTS FILED WITH STATES CO 1 COLORADO STATE UNIVERSITY 601 S HOWES ST FORT COLLINS CO 80523 846000545 GOVERNMENT 1001200 SEE SCH I, PART IV DOWNTOWN BUSINESS ASSOCIATION 19 OLD TOWN SQUARE 230 FORT COLLINS CO 80524 840535419 501(C )(3) 30000 SEE SCH I, PART IV GREELEY CENTENNIAL ROTARY 1035 37TH AVE CT GREELEY CO 80634 840714073 501(C )(3) 7500 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 N 30TH STREET LARAMIE WY 82072 836000188 501(C )(3) 6350 SEE SCH I, PART IV MARCH OF DIMES 1325 S COLORADO BLVD B308 DENVER CO 80222 131846366 501(C )(3) 12500 SEE SCH I, PART IV POUDRE VALLEY MEDICAL GROUP 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 800348943 N/A 23197544 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 17TH PLACE AURORA CO 80045 846000555 501(C )(3) 5900180 SEE SCH I, PART IV THE COMMUNITY FOUNDATION 4745 WHEATON DR 100 FORT COLLINS CO 80528 840699243 501(C )(3) 6970 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE ST 102 FORT COLLINS CO 80524 846031503 501(C )(3) 39146 SEE SCH I, PART IV UNIVERSITY OF N COLORADO 501 20TH STREET GREELEY CO 80639 846000546 GOVERNMENT 49400 SEE SCH I, PART IV NORTHERN COLORADO UNITED FOR YOU 2015 CLUBHOUSE 203 GREELEY CO 80634 208575428 501(C )(3) 24500 SEE SCH I, PART IV PVH FOUNDATION 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 962661 SEE SCH I, PART IV 11 1 PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION I, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KEVIN UNGER PRESIDENT/CEO 226390 226390 302581 302581 9832 9832 3900 3900 50277 50276 592980 592979 229185 229185 STEPHANIE DOUGHTY CFO 239943 239943 51939 51939 1391 1391 3900 3900 27030 27029 324203 324202 0 0 DONNA PODUSKA CNO 192486 0 39783 0 3009 0 7001 0 26363 0 268642 0 0 0 MICHAEL RANDLE CMO, CHMG 311394 0 56513 0 1900 0 7800 0 46237 0 423844 0 0 0 STANLEY GUNSTREAM VP CHIEF QUALITY OFFICER 335414 0 61259 0 2967 0 7800 0 44239 0 451679 0 0 0 KENNETH WATANABE PSYCHIATRIST 249067 0 19012 0 375 0 7800 0 38652 0 314906 0 0 0 JANELL WOZNIAK PHYSICIAN-RESIDENCY PGRM DIRECTOR 248571 0 20893 0 324 0 6454 0 39374 0 315616 0 0 0 JOSEPH GOTTFRIED PSYCHIATRIST 253216 0 4230 0 634 0 7800 0 39867 0 305747 0 0 0 DANNY ROBINSON CEO, CHMG 213592 96001 0 101303 1461 1216 6660 1200 29425 20796 251138 220516 0 0 STEVEN SCHWARTZ CFO, CHMG 94415 88080 0 36308 202 289 2888 3776 13931 16653 111436 145106 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS: PER SYSTEM POLICY, TRAVEL FOR COMPANIONS IS NOT REIMBURSABLE. FOR CONVENIENCE OF TRAVEL ARRANGEMENTS FOR THE ANNUAL BOARD MEMBER RETREAT AND SELECT CONFERENCES, PVHC PAYS FOR ONE COMPANION PER BOARD MEMBER AND EMPLOYEE ATTENDING THE CONFERENCE. EACH BOARD MEMBER RECEIVES A FORM 1099 FOR THIS INCOME. EACH EMPLOYEE HAS THIS ADDED TO THEIR FORM W-2. GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, PERSONAL USE OF LAPTOP COMPUTERS AND IPADS, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. A COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26294807 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2015 SERIES A 841179794 914183AV0 2015-02-04 70500000 CONSTRUCTION COSTS AT PVH 0 0 0 D UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2015 SERIES C 841179794 914183AX6 2015-02-04 56850000 REFUNDING 2005F BONDS 0 0 0 A 50000000 3133031 433893 3097393 46468713 2005 0 1 1 1 B 26294807 1644630 397052 897754 25000000 2005 1 0 1 1 C 70500000 625100 828412 69671588 2015 0 0 0 1 D 56850000 436806 56413194 2015 0 1 1 1 A 0 1 0 0 0.00250 0.00250 0 0 1 B 0 1 0 0 0.00250 0.00250 0 0 1 C 0 1 0 0 0.00250 0.00250 0 0 1 D 0 1 0 0 0.00250 0.00250 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 1 0 0 1 0 0 0 1 D 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 SCHEDULE K, PART I, COLUMN E BOND ISSUE PRICE THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH A RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 8038: $83,000,000. SCHEDULE K, PART IV, LINE 2C THE REBATE CALCULATION WAS PERFORMED IN APRIL 2015 FOR BOND ISSUANCES A AND B. KATHLEEN MICHIE SEE PART V 65727 SEE PART V 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS (A) NAME OF PERSON: KATHLEEN MICHIE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: KATHLEEN MICHIE IS A FAMILY MEMBER OF THAINE MICHIE, DIRECTOR(D) DESCRIPTION OF TRANSACTION: W-2 WAGES X MEDICAL EQUIPMENT 59 1347005 FMV X SECURITY EQUIPMENT 1 139871 FMV 0 0 0 FORM 990, PART I, LINE 6 VOLUNTEERS PVH HAS 600 ACTIVE VOLUNTEERS IN FISCAL YEAR 2015. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEENS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 UCHEALTH CONTRACTS WITH HAYGROUP FOR EXECUTIVE COMPENSATION CONSULTING SERVICES. ON OUR BEHALF THE HAYGROUP COLLECTS AND REVIEWS COMPENSATION LEVELS FROM LIKE ORGANIZATION FOR LIKE JOBS AND PROVIDES UCHEALTH WITH THE COMPARATIVE MARKET DATA. THE DATA IS SUBMITTED TO THE CHIEF HUMAN RESOURCES OFFICER WHO ADVICES THE SYSTEM PRESIDENT AND CEO ON COMPENSATION DECISIONS FOR SENIOR EXECUTIVES. BASED ON THE MARKET DATA, THE SYSTEM PRESIDENT AND CEO DETERMINES THE SALARY OF THE ENTITY CEO'S COMPENSATION ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. FORM 990, PART XI, LINE 9: MCR DISTRIBUTIONS TO PVH 43,135,400. AUXILIARY INCOME ON 990, NOT IN AUDIT -98,022. DONATION TO FOUNDATION FROM AUXILLIARY NOT IN AUDIT EXPENSE 109,000. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 37,679,904. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO 42647 256098 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 5538239 16883808 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO -19096 657338 PVHC INC UNITED MED ALLIANCE 2021 BATTLECREEK DRIVE STE A FORT COLLINS CO 80528 820572743 HEALTH CLAIMS CO 603045 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 1900616 2787702 0 0 0.50000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED -270611 884752 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 186453 421030 0 0 0.50000 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FORT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 62032 97390 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FORT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 4091236 10495595 0 0 0.50000 POUDRE INFUSION THERAPY 947 WORTHINGTON CIRCLE FORT COLLINS CO 80526 841530973 MEDICAL SERVICES CO N/A RELATED -46748 -90990 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED 199583 1214186 0 1 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FORT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED 10719 44089 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 911267 1515800 0 0 0.46000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD STE 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A RELATED 101918 69981 0 0 0.14290 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 557406 1111652 0 0 0.26000 POUDRE VALLEY MEDICAL GROUP LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 MEDICAL SERVICES CO N/A RELATED -35583712 24787427 0 1 0.99000 PVHS-ICM EHW 3702 AUTOMATION WAY 103 FORT COLLINS CO 80525 463311308 MEDICAL SERVICES CO N/A RELATED -24509 147454 0 0 0.50000 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO PVHC C 981858 2385612 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 1 1 HARMONY SURGERY CENTER A 914950 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 587134 TRANSACTION TOTAL HARMONY SURGERY CENTER S 1762097 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 195382 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO S 63000 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 4752551 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 7692636 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 7063079 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES S 43135400 TRANSACTION TOTAL PVHS FOUNDATION B 914115 TRANSACTION TOTAL PVHS FOUNDATION C 1572744 TRANSACTION TOTAL PVHS FOUNDATION L 65301 TRANSACTION TOTAL PVHS FOUNDATION N 71335 TRANSACTION TOTAL INNOVATION ENTERPRISES A 116939 TRANSACTION TOTAL INNOVATION ENTERPRISES A 265445 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 23197253 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 3179116 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 3728747 TRANSACTION TOTAL