2015-02-25T07:47:54-06:00 2014-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2013-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS CEO, SECRETARY AND TREASURER 4063754609 2015-02-24 1 DARRYN MCGARVEY P00958683 6123764500 2013 2016-02-25 16:41:14Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 57766535 0 X WWW.MDMH.ORG X 1938 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 7 632 90 0 0 159689 1086784 53603950 56277773 -78746 -17311 125118 207321 53810011 57554567 71106 25756 0 0 31423605 33925556 0 0 183897 23414247 22193650 54908958 56144962 -1098947 1409605 55319551 56805326 29790802 30001919 25528749 26803407 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 1 47346457 25756 56277773 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 25 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY, THERAPY, INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS A PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 47346457 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 69 0 632 1 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X X DONJA ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 DON LODMELL PHD CHAIRMAN 2.00 X X 0 0 0 BILL BEAN VICE CHAIR 2.00 X X 0 0 0 BARBARA ACKERMAN BOARD MEMBER 2.00 X 0 0 0 WALKER ASHCRAFT MD BOARD MEMBER/PHYSICIAN 40.00 X 129994 0 22808 GARY BEDEY BOARD MEMBER 2.00 X 0 0 0 SUSANNAH BENJAMIN BOARD MEMBER 2.00 X 0 0 0 DONNA COONEY BOARD MEMBER 2.00 X 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN 40.00 X 236371 0 13000 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 40.00 X 227292 0 0 JAMES OWINGS CPA BOARD MEMBER 2.00 X 0 0 0 JOHN ORMISTON BOARD MEMBER 2.00 X 0 0 0 RANDY STEWART MD BOARD MEMBER/PHYSICIAN THRU OCT 2014 2.00 X 11899 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 39.00 1.00 X 277889 0 32076 DONJA C ERDMAN CFO 39.00 1.00 X 104416 0 27104 JOHN MORELAND MD CHIEF MEDICAL OFFICER 40.00 X 251587 0 39012 TROY HANSON ASSISTANT ADMINISTRATOR 40.00 X 150188 0 10418 SUSAN HILL RN DIRECTOR OF NURSING 40.00 X 109623 0 7890 RICHARD DAY MD PHYSICIAN 40.00 X 856953 0 312 JEREMIAH CLINTON MD PHYSICIAN 40.00 X 407638 0 43089 YVONNE COURCHESNE MD PHYSICIAN 40.00 X 324050 0 35146 MARK CALDERWOOD MD PHYSICIAN 40.00 X 322625 0 23886 LUKE CHANNER MD PHYSICIAN 40.00 X 306517 0 38293 3717042 0 293034 30 0 1 0 JACKSON CONTRACTOR GROUP INC PO BOX 967 MISSOULA MT 59806 GENERAL CONTRACTOR 962242 CERNER CORPORATION PO BOX 412072 KANSAS CITY MO 64141 BUSINESS SERVICES PROVIDER 886206 SIRIUS CONSTRUCTION INC 825 COOPER MISSOULA MT 59802 GENERAL CONTRACTOR 795071 OZ ARCHITECTS 5310 NORTH HIGGINS AVE A MISSOULA MT 59806 ARCHITECTUAL FEES 606145 ALLIANCE HEALTHCARE SERVICES FILE 55826 LOS ANGELES CA 90074 MRI IMAGING 453927 18 888013 198771 1086784 NET PATIENT SERVICE REVENUE 621400 54625434 54625434 HOSPITAL UTILZTN. REV. 621400 963369 963369 OTHER OPERATING INCOME 621400 688970 688970 56277773 34571 34571 143 143 228683 152445 76238 76238 76238 7498 59523 -52025 -52025 -52025 MISCELLEANEOUS 900099 109976 109976 EDUCATION 900099 15485 15485 CAFETERIA/VENDING 900099 5622 5622 131083 57554567 56277773 0 190010 25756 25756 1729993 1116385 613608 25778094 21618567 4061845 97682 978862 826414 148722 3726 3698886 3078145 607451 13290 1739721 1407567 324592 7562 90909 90909 60378 60378 2959338 1455756 1501871 1711 91806 91806 557232 244992 308464 3776 797848 638321 159527 318060 299982 17999 79 177964 147964 30000 1140440 945982 155566 38892 4223589 4013607 196514 13468 898139 898139 PROVISION FOR BAD DEBTS 5736336 5736336 MEDICAL SUPPLIES EXPENS 3333455 3333455 MAINTENANCE AND REPAIRS 816916 670210 144406 2300 PHARMACY/ LAB EXPENSES 520281 520281 470959 276792 192756 1411 56144962 47346457 8614608 183897 6073256 5572347 3398704 2810312 9154138 9878544 -1594 -30000 1292887 1468768 422439 451378 62696368 28459623 32518091 34236745 2032918 1929655 428712 487577 55319551 56805326 8586884 7046744 352505 293755 7635000 7165000 10894698 13043144 166521 500000 2155194 1953276 29790802 30001919 X 23022484 24308870 1815208 1802320 691057 692217 25528749 26803407 55319551 56805326 X 1409605 -134947 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 2806 2806 313190 313190 2665 2665 313190 313190 1997 1997 313190 313190 3160 3160 313190 313190 4071 4071 313190 0.00000 1.00000 0.00000 0 0 1637827 1637827 39462270 15528590 23933680 763710 551150 212560 17412411 12379883 5032528 3420150 3420150 34236745 THIRD PARTY SETTLEMENT 1953276 1953276 X 50715589 -5736336 -5736336 56451925 1102642 1102642 57554567 50588228 179602 179602 50408626 5736336 5736336 56144962 PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. PART X, LINE 2: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. THE HOSPITAL'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATION TAX RETURNS FOR THE YEARS ENDED 2011 TO 2013 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -5,736,336. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST REVENUE 34,714. UNRESTRICTED CONTRIBUTIONS 104,339. OTHER NONOPERATING REVENUE 168,015. TEMPORARILY RESTRICTED CONTRIBUTIONS 982,445. RENTAL EXPENSES -134,846. LOSS ON DISPOSAL OF FIXED ASSETS -52,025. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 134,846. MDMH MAMMOGRAPHY FUND MATCH 44,756. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 5,736,336. 1 1 X 1 X 1 X 1 1 1 0 1 1 846292 846292 0.01680 4894270 3449335 1444935 0.02870 5740562 3449335 2291227 0.04550 315081 315081 0.00630 224058 224058 0.00440 4048352 2428911 1619441 0.03210 73798 73798 0.00150 4661289 2428911 2232378 0.04430 10401851 5878246 4523605 0.08980 763 763 0.00000 42840 42840 0.00080 43603 43603 0.00080 1 5736336 0 16131224 16945328 -814104 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL 1200 WESTWOOD DRIVE HAMILTON MT 59840 X X X X MARCUS DALY MEMORIAL HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X HTTP://WWW.MDMH.ORG/DOCS/COMMUNITY_HEALTH X X X X X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X X X 1 1 X X X 1 0 X X 1 X 0 0 MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: THOSE ZIP CODES WITH THE GREATEST NUMBER OF ADMISSIONS WERE SELECTED TO BE INCLUDED IN THE SURVEY. A RANDOM LIST OF 800 RESIDENTS WERE SELECTED FROM PRIME NET DATA SOURCE. ADDITIONALLY, THREE FOCUS GROUPS WERE HELD TO IDENTIFY THE MOTIVES OF LOCAL RESIDENTS WHEN SELECTING HEALTH CARE PROVIDERS. NOTICE OF THE SURVEY WAS PLACED IN THE LOCAL NEWSPAPER. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 10: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATION 1)RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2)FAMILY NET ASSETS 3)DEMONSTRATION OF INABILITY TO WORK 4)COMPLETED APPLICATION AND 5)RESIDENT OF RAVALLI COUNTY WITH EXCEPTIONS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATION 1)RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2)FAMILY NET ASSETS 3)DEMONSTRATION OF INABILITY TO WORK 4)COMPLETED APPLICATION AND 5)RESIDENT OF RAVALLI COUNTY WITH EXCEPTIONS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: AS OF JANUARY 1, 2014, THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM WAS ALSO POSTED ON THEIR WEBSITE AT HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16E: ACCOUNTS THAT CANNOT BE COLLECTED BY MDMH AFTER A NORMAL COLLECTION PROCEDURE MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION IN ACCORDANCE WITH ESTABLISHED GUIDELINES. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: MDMH DETERMINES AMOUNTS GENERALLY BILLED ("AGB") BASED ON COMMERCIAL PAYORS. THE LARGEST COMMERCIAL PAYOR DISCOUNT WAS 27% FOR THE YEAR ENDED JUNE 30, 2014. PATIENT FINANCIAL ASSISTANCE DISCOUNTS RANGE FROM 30% TO 100%, DEPENDING UPON PATIENT ELIGIBILITY. 4 CORVALLIS FAMILY MEDICINE CLINIC 1037 MAIN STREET CORVALLIS MT 59828 FAMILY PRACTICE CLINIC BITTERROOT VALLEY EYE ASSOCIATES 300 N 10TH STREET HAMILTON MT 59840 OPTICAL SPECIALTY CLINIC BITTERROOT VALLEY EYE ASSOCIATES 401 MAIN STREET STEVENSVILLE MT 59870 OPTICAL SPECIALTY CLINIC RAVALLI UROLOGY 1224 MAIN STREET HAMILTON MT 59840 UROLOGY SPECIALTY CLINIC PART I, LINE 3C: FULL TO PARTIAL ASSISTANCE MAY BE GRANTED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG, AS ADJUSTED FOR FAMILY SIZE. PART I, LINE 6A: A COMMUNITY BENEFIT REPORT FOR THE REPORTING YEAR ENDED 6/30/2014 WAS IN THE FALL 2014 EDITION OF HEALTHLINES THE NEWSLETTER OF MARCUS DALY MEMORIAL HOSPITAL. THE NEWSLETTER WAS DELIVERED TO EVERY MAILING ADDRESS IN RAVALLI COUNTY COVERING APPROXIMATELY 14,300 HOUSEHOLDS. AN ADDITIONAL 1,000 COPIES OF THE NEWSLETTER WERE PRINTED FOR GENERAL CIRCULATION. PART I, LINE 7: EXPLANATION OF COSTING METHOD:COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET OF PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTAL SUBSIDY FOR THE HOME HEALTH/HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS:HOME HEALTH, HOSPICE CENTER AND HOSPICE OUTPATIENT, HOSPITALIST PROGRAM, THE ROCKY MOUNTAIN NEUROLOGY SURGERY CLINIC, BITTERROOT GENERAL VASCULAR SURGERY CENTER, AND HAMILTON GENERAL SURGERY CENTER. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $5,736,336. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. THE HOSPITAL IS ALSO ACTIVELY INVOLVED IN NUMEROUS COMMUNITY SUPPORT ORGANIZATIONS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT RECEIVABLES" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL 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 HOSPITAL 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."THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $814,104. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WAS DERIVED USING THE 2014 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PATIENT FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE PATIENT FINANCIAL ASSISTANCE COMMITTEE FOR REVIEW AND DETERMINATION OF PATIENT FINANCIAL ASSISTANCE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE BALANCE PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: MARCUS DALY MEMORIAL HOSPITAL PARTICIPATED IN THE COMMUNITY HEALTH SERVICES DEVELOPMENT (CHSD) PROJECT ADMINISTRATED BY THE MONTANA OFFICE OF RURAL HEALTH AND THE NATIONAL RURAL HEALTH RESOURCE CENTER (NRHRC) IN DULUTH, MINNESOTA. PART VI, LINE 3: BILLING AND COLLECTION INFORMATION IS LOCATED ON THE BACK OF THE STATEMENT SENT TO PATIENTS ON A MONTHLY BASIS, WE CONTACT BY PHONE REQUESTING PAYMENT AND MAY EXPLAIN POLICIES AT THAT TIME. WE UTILIZE THE MASH PROGRAM TO SCREEN PRIVATE PAY PATIENTS TO QUALIFY FOR OTHER PROGRAMS SUCH AS MEDICAID AND DISABILITY. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE HOUSEHOLD MEDIAN INCOME IS ABOUT $28,000. THE PAYER MIX IS 54% MEDICARE, 10% MEDICAID, 11% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE UNEMPLOYMENT RATE IN RAVALLI COUNTY IS CURRENTLY AT 6% ACCORDING TO THE MONTANTA DEPARTMENT OF LABOR AND INDUSTRY. PART VI, LINE 5: THE HOSPITAL IS PROUD OF IT'S EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. THIS YEAR THE FOCUS WAS ON THE "SPRINKLE PINK" PROGRAM WHICH PROMOTED COMMUNITY AWARENESS AS TO THE IMPORTANCE OF MAMMOGRAPHY SCREENING. THE HOSPITAL SPONSORS AN ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICIAL ACTIVITIES. OTHER COMMUNITY CLINICS OR SCREENINGS INCLUDED BLOOD PRESSURE TESTING AT AREA SENIOR CENTERS, AND LIPID PROFILES AND CHOLESTEROL TESTS PROVIDED TO THE COMMUNITY FREE OF CHARGE. A VARIETY OF HEALTH EDUCATION CLASSES WERE CONDUCTED INCLUDING A ONE-DAY WORKSHOP FOCUSED ON WOMEN'S HEART HEALTH. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES MT 1 HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 10025 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 8650 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6525 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS 3 0 PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X 1 0 X X X 0 0 0 0 0 0 0 0 0 WALKER ASHCRAFT MD BOARD MEMBER/PHYSICIAN 129994 0 0 0 0 0 15984 0 6824 0 152802 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN 236371 0 0 0 0 0 12000 0 1000 0 249371 0 0 0 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 227292 0 0 0 0 0 0 0 0 0 227292 0 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 273089 0 0 0 4800 0 23000 0 9076 0 309965 0 0 0 JOHN MORELAND MD CHIEF MEDICAL OFFICER 251587 0 0 0 0 0 39012 0 0 0 290599 0 0 0 TROY HANSON ASSISTANT ADMINISTRATOR 150188 0 0 0 0 0 0 0 10418 0 160606 0 0 0 RICHARD DAY MD PHYSICIAN 856953 0 0 0 0 0 0 0 312 0 857265 0 0 0 JEREMIAH CLINTON MD PHYSICIAN 407638 0 0 0 0 0 35000 0 8089 0 450727 0 0 0 YVONNE COURCHESNE MD PHYSICIAN 324050 0 0 0 0 0 35000 0 146 0 359196 0 0 0 MARK CALDERWOOD MD PHYSICIAN 322625 0 0 0 0 0 17500 0 6386 0 346511 0 0 0 LUKE CHANNER MD PHYSICIAN 306517 0 0 0 0 0 28863 0 9430 0 344810 0 0 0 PART I, LINE 1A DR RICHARD DAY RECEIVES A HOUSING ALLOWANCE OF $7,200 THAT IS NOT INCLUDED IN HIS TAXABLE INCOME. THE HOUSE IS PROVIDED TO DR DAY AS A CONVENIENCE TO MARCUS DALY MEMORIAL HOSPITAL. PART I, LINE 1B THE CEO HAS BEEN APPROVED BY THE BOARD OF DIRECTORS TO RECEIVE A MONTHLY $400 VEHICLE ALLOWANCE. A MT HEALTH FACILITY AUTHORITY 810302406 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 A 1590000 7135000 948032 155264 5973474 2008 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: MT HEALTH FACILITY AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 08/01/2011 PART II, LINE 3, PROCEEDS OF ISSUE THE ISSUE PRICE OF $7,068,924 (PART I, COLUMN E) DOES NOT EQUAL THE TOTAL PROCEEDS OF ISSUE OF $7,135,000 (PART II, LINE 3) BECAUSE OF A $66,076 ORIGINAL ISSUE DISCOUNT. KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 126355 EMPLOYMENT 0 FORM 990, PART III, LINE 3 THE ORGANIZATION CLOSED THE TRANSITIONAL CARE UNIT FORM 990, PART VI, SECTION B, LINE 11 A REPRESENTATIVE FROM CLIFTONLARSONALLEN WILL BE RESPONSIBLE TO PRESENT THE FORM 990 TO THE HOSPITAL FINANCE COMMITTEE. UPON APPROVAL THE FORM 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, CORPORATE OFFICER, SENIOR MANAGER, TRUSTEE OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS AN INTERESTED PERSON. IF A PERSON IS AN INTERESTED PERSON WITH RESPECT TO ANY ENTITY IN THE HEALTH CARE SYSTEM OF WHICH THE HOSPITAL IS A PART, HE OR SHE IS AN INTERESTED PERSON WITH RESPECT TO ALL ENTITIES IN THE HEALTH CARE SYSTEM. UPON APPOINTMENT, HIRE OR TRANSFER AND ANNUALLY THEREAFTER, EACH INTERESTED PERSON SHALL EXECUTE AND SUBMIT TO THE HOSPITAL'S CEO A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY; B. HAS READ AND UNDERSTANDS THE POLICY; C. HAS AGREED TO COMPLY WITH THE POLICY; AND D. UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL AND STATE TAX EXEMPTIONS IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE CONFLICTING FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. ANY OTHER MEMBER OF THE BOARD OR COMMITTEE MAY RAISE THE QUESTION OF WHETHER A CONFLICT EXISTS, DISCLOSE FACTS RELATING TO THE CONFLICT AND REQUEST THE INTERESTED PERSON TO PROVIDE FURTHER DETAILS. THE BOARD CHAIR (OR VICE CHAIR ACTING IN THE PLACE OF THE CHAIR) OR THE HOSPITAL'S LEGAL COUNSEL MAY, BASED ON THEIR INFORMATION ABOUT THE CONFLICT, DISCLOSE THE CONFLICT AND REQUEST THE INTERESTED PERSON TO WITHDRAW FROM DISCUSSION OF THE TRANSACTION AND/OR NOT VOTE. THE INTERESTED PERSON SHALL LEAVE THE MEETING OR REQUEST A DETERMINATION BY THE BOARD OR COMMITTEE OF WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE CONFLICTING INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING, DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BEFORE CONSIDERING OR ACTING UPON ANY OTHER BUSINESS. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 CEO - OCCURS ANNUALLY WITH ANNUAL COMPENSATION COMMITTEE OF THE BOARD. THE COMMITTEE REVIEWS SURVEYS FOR COMPARABLE PAY AND BENEFITS. THIS COMMITTEE ALSO CONDUCTS THE ANNUAL EVALUATION OF THE CFO. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, A COPY OF THE FORM 990 IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION -103,263. AUXILIARY 13,072. ADJUSTMENT FOR MDMH MAMMOGRAPHY FUND MATCH -44,756. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) 11-TYPE 2 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 DALY HOSPITAL FOUNDATION INC L 149736 FAIR VALUE DALY HOSPITAL FOUNDATION INC C 888013 FAIR VALUE