2014-05-06T10:13:46-05:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS 4063754609 2014-05-01 1 DARRYN MCGARVEY P00958683 6123764500 2012 2015-11-30 17:44:51Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 54099514 0 X WWW.MDMH.ORG X 1938 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 6 577 90 0 0 115352 159689 51546346 53603950 15311 -78746 194464 125118 51871473 53810011 76726 71106 0 0 28395994 31423605 0 0 216283 23871665 23414247 52344385 54908958 -472912 -1098947 49935753 55319551 23861018 29790802 26074735 25528749 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 1 0 46190989 71106 53603950 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 48 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL WITH 25 BEDS SETUP. 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 AND THERAPY INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, AND 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 THE ONLY PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY IN WESTERN MONTANA USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 46190989 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 72 0 577 0 0 0 0 0 0 0 0 0 0 0 X 11 6 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 2.00 X X 0 0 0 BILL BEAN 2.00 X X 0 0 0 BARBARA ACKERMAN 2.00 X 0 0 0 WALKER ASHCRAFT MD 40.00 X 133923 0 23031 GARY BEDEY 2.00 X 0 0 0 SUSANNAH BENJAMIN 2.00 X 0 0 0 DONNA COONEY 2.00 X 0 0 0 FREDERICK ILGENFRITZ MD 40.00 X 248881 0 11800 BRIAN KELLEHER MD 40.00 X 208876 0 0 JAMES OWINGS CPA 2.00 X 0 0 0 RANDY STEWART MD 3.00 X 61548 0 0 STEVEN ELLIS MD 2.00 X 0 0 0 SONNY LASALLE 2.00 X X 0 0 0 JOHN M BARTOS 39.00 1.00 X 297133 0 36347 DONJA C ERDMAN 39.00 1.00 X 123565 0 26097 JOHN MORELAND MD 40.00 X 275072 0 38991 JEREMIAH CLINTON MD 40.00 X 441891 0 26567 FRANK MCHUGH MD 40.00 X 316384 0 17333 MATTHEW MUNDING MD 40.00 X 248261 0 42109 JOHN LARAWAY MD 40.00 X 271900 0 16509 WILLIAM DOYLE MD 40.00 X 256284 0 28019 2883718 0 266803 31 0 1 0 QUALITY CONSTRUCTION INC PO BOX 4746 MISSOULA MT 59806 GENERAL CONTRACTOR FEES 781462 OZ ARCHITECTS 5310 NORTH HIGGINS AVE A MISSOULA MT 59806 ARCHITECTUAL FEES 557105 ALLIANCE HEALTHCARE SERVICES FILE 55826 LOS ANGELES CA 90074 MRI IMAGING 550798 HEALTHCARE OUTSOURCING NETWORK LLC 621 17TH ST 1800 DENVER CO 80293 BUSINESS SERVICES PROVIDER 514028 CERNER CORPORATION PO BOX 412072 KANSAS CITY MO 64141 BUSINESS SERVICES PROVIDER 387195 16 159689 159689 NET PATIENT SERVICE REVENUE 621400 51565492 51565492 HOSPITAL UTILZTN. REV. 621400 1268604 1268604 OTHER OPERATING INCOME 621400 769854 769854 53603950 12672 12672 7234 7234 179766 174805 4961 4961 4961 16046 114698 -98652 -98652 -98652 MISCELLEANEOUS 900099 89470 89470 EDUCATION 900099 24639 24639 CAFETERIA/VENDING 900099 6048 6048 120157 53810011 53603950 0 46372 71106 71106 1409747 954211 455536 23920944 19882650 3922610 115684 886641 739836 142510 4295 3520994 2906364 598418 16212 1685279 1315374 361529 8376 71029 71029 67832 67832 3888407 2292479 1593761 2167 119443 119443 3909728 3577986 330085 1657 756808 580457 176351 333920 318435 15485 166937 116567 50366 4 984171 791338 154266 38567 3845520 3667463 164954 13103 886534 886534 PROVISION FOR BAD DEBTS 7180083 7180083 MAINTENANCE AND REPAIRS 671266 556770 112952 1544 MISCELLANEOUS EXPENSES 328013 37712 275627 14674 PHARMACY/ LAB EXPENSES 169440 169440 35116 26741 8375 54908958 46190989 8501686 216283 7077081 6073256 2642542 3398704 9148211 9154138 9261 -1594 1198333 1292887 371702 422439 57660043 25141952 27577068 32518091 1452688 2032918 458867 428712 49935753 55319551 6512071 8586884 719442 352505 8085000 7635000 7425464 10894698 426904 166521 692137 2155194 23861018 29790802 X 24190477 23022484 900075 1815208 984183 691057 26074735 25528749 49935753 55319551 X -1098947 552961 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 2665 2665 313190 313190 1997 1997 313190 313190 3160 3160 313190 313190 4071 4071 313190 313190 313190 0.00000 1.00000 0.00000 0 0 1637827 1637827 37163469 13578580 23584889 737267 493027 244240 15898604 11070345 4828259 2222876 2222876 32518091 THIRD PARTY SETTLEMENT 2155194 2155194 X 46438684 -7180083 -7180083 53618767 191244 191244 53810011 47880832 151957 151957 47728875 7180083 7180083 54908958 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 2010 TO 2012 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -7,180,083. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST REVENUE 19,906. UNRESTRICTED CONTRIBUTIONS 36,038. OTHER NONOPERATING REVENUE 163,606. TEMPORARILY RESTRICTED CONTRIBUTIONS 123,651. RENTAL EXPENSES -151,957. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 151,957. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 7,180,083. 1 1 X 1 X 1 X 1 1 1 0 1 1 2 346 737080 737080 0.01540 4492557 3067240 1425317 0.02990 2 346 5229637 3067240 2162397 0.04530 431921 431921 0.00900 137727 137727 0.00290 2884532 1650817 1233715 0.02580 66784 66784 0.00140 3520964 1650817 1870147 0.03910 2 346 8750601 4718057 4032544 0.08440 7030 7030 0.00010 1448 1448 0.00000 201660 201660 0.00420 210138 210138 0.00430 1 7180083 0 15392126 16115432 -723306 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 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 1 1 X X 1 0 X X 1 X 0 0 5 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 CLINIC

1224 MAIN STREET HAMILTON MT 59840

FAMILY PRACTICE 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: A FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 CURRENT VALUE, INCLUDING A HOME AND ONE OR TWO CARS (IF TWO ADULTS IN FAMILY). OWNERSHIP IN LIVESTOCK, RECREATIONAL VEHICLES AND SIMILAR TYPE ITEMS WILL DISQUALIFY THE FAMILY FROM CHARITY CARE (UNLESS RELATED TO PRIMARY SOURCE OF INCOME AND INCLUDED ON MOST RECENT FEDERAL TAX FILING). A FAMILY MAY NOT OWN GROSS ASSETS (WITHOUT CONSIDERATION OF MORTGAGE OR OTHER LOANS ON PROPERTY) IN EXCESS OF $200,000. PART I, LINE 6A: A COMMUNITY BENEFIT REPORT FOR FISCAL YEAR 2012 WAS IN THE SPRING 2013 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:AMBULANCE, HOME HEALTH, HOSPICE CENTER AND HOSPICE OUTPATIENT, HOSPITALIST PROGRAM, AND THE ROCKY MOUNTAIN NEUROLOGY SURGERY CLINIC. PART I, L7 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 $7,180,083. PART II: 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 RATESIF 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 $723,000. 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 2013 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. 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 WAS 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 5C: MDMH'S COMMUNITY HEALTH NEEDS ASSESSMENT WAS AVAILABLE ON THEIR WEBSITE AS OF JANUARY 1, 2104 AT: HTTP://WWW.MDMH.ORG/DOCS/COMMUNITY_HEALTH_NEEDS_ASSESSMENT_REPORT_2012.PDF?SUB=PATIENT%20INFO MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 10: ELIGIBILITY FOR PATIENT ASSISTANCE IS MADE REGARDLESS OF RACE, COLOR, CREED, OR AGE. COSMETIC OR EXPERIMENTAL PROCEDURES AND CHARGES ARE NOT ELIGIBLE FOR PATIENT FINANCIAL ASSISTANCE. FULL TO PARTIAL PATIENT ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG AS ADJUSTED FOR FAMILY SIZE. THE FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 OR GROSS ASSETS OVER $200,000. OTHER CONSIDERATIONS MAY BE A PATIENT'S HEALTHINESS AND THEIR ABLILTY TO SEEK OR HOLD EMPLOYEMENT. SEE PATIENT FINANCIAL ASSISTANCE POLICY FOR DETAILS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ELIGIBILITY FOR PATIENT ASSISTANCE IS MADE REGARDLESS OF RACE, COLOR, CREED OR AGE. COSMETIC OR EXPERIMENTAL PROCEDURES AND CHARGES ARE NOT ELIGIBLE FOR CHARITY ASSISTANCE. FULL TO PARTIAL PATIENT ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG AS ADJUSTED FOR FAMILY SIZE. THE FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 OR GROSS ASSETS OVER $200,000. SEE CHARITY CARE POLICY FOR DETAILS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: AS OF JANUARY 1, 2014, THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY WAS ALSO POSTED ON THEIR WEBSITE AT HTTP://WWW.MDMH.ORG/DOCS/CHARITYCAREPOLICY.PDF?SUB=PATIENT%20INFO. 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 20% FOR THE YEAR ENDED JUNE 30, 2013. PATIENT FINANCIAL ASSISTANCE DISCOUNTS RANGE FROM 30% TO 100%, DEPENDING UPON PATIENT ELIGIBILITY. 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 55% MEDICARE, 9% MEDICAID, 12% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE PERIOD UNEMPLOYMENT RATE HAS RANGED BETWEEN 9 AND 10.2% 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. REPORTS FILED WITH STATES PART VI, LINE 7 MT 1 HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 9700 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 8950 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6500 SUPPORT FOR SCHOOL RN PROGRAM. 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 0 0 X X X 0 0 0 0 0 0 0 0 0 WALKER ASHCRAFT MD 133923 0 0 0 0 0 15984 0 7047 0 156954 0 0 0 FREDERICK ILGENFRITZ MD 248881 0 0 0 0 0 10800 0 1000 0 260681 0 0 0 BRIAN KELLEHER MD 208876 0 0 0 0 0 0 0 0 0 208876 0 0 0 JOHN M BARTOS 292333 0 0 0 4800 0 22500 0 13847 0 333480 0 0 0 JOHN MORELAND MD 275072 0 0 0 0 0 38991 0 0 0 314063 0 0 0 JEREMIAH CLINTON MD 441891 0 0 0 0 0 18458 0 8109 0 468458 0 0 0 FRANK MCHUGH MD 316384 0 0 0 0 0 17000 0 333 0 333717 0 0 0 MATTHEW MUNDING MD 248261 0 0 0 0 0 34000 0 8109 0 290370 0 0 0 JOHN LARAWAY MD 271900 0 0 0 0 0 8400 0 8109 0 288409 0 0 0 WILLIAM DOYLE MD 256284 0 0 0 0 0 19045 0 8974 0 284303 0 0 0 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 810302402 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 A 1300000 7135000 1006262 155264 5973474 2008 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 SCHEDULE K PART IV, ARBITRAGE, LINE 2C 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 105746 EMPLOYMENT 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 ADDED NEURO SURGERY CLINIC FORM 990, PART VI, SECTION B, LINE 11 A REPRESENTATIVE FROM CLIFTONLARSONALLEN WILL BE RESPONSIBLE TO PRESENT THE FORM 990 TO THE HOSPITAL FINANCE COMMITTE. UPON APPROVAL THE FORM 990 WILL BE PRESENTED TO THE ENTIRE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL ATTORNEY ATTENDS ALL BOARD MEETINGS AND HE IS GIVEN THE AUTHORITY TO QUESTION, PRIOR TO DISCUSSION, A POTENTIAL CONFLICT OF INTEREST FOR ANY DIRECTOR. THE CEO RAISES A QUESTION REGARDING CONFLICT OF INTEREST. THE HOSPITAL BOARD ASKS THE DIRECTOR TO STEP OUT OF THE ROOM DURING DISCUSSION OF CONFLICT. THE DIRECTOR IS EXCUSED FOR THE DISCUSSION ONCE A CONFLICT HAS BEEN DETERMINED OR IS INVITED BACK INTO THE ROOM IF NO CONFLICT IS DETERMINED TO EXIST. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 580,230. AUXILIARY -27,269. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) 11-TYPE 2 N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0