2014-05-14T09:50:55-05:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-07-01 810247705 COMMUNITY MEDICAL CENTER INC COMM 4067284100 2827 FORT MISSOULA ROAD MISSOULA MT 59804 DAVID RICHHART 4067284100 2014-04-29 1 ROBERT E SCHILE P00369682 6123764500 2012 2015-11-30 17:44:51Z STEVE CARLSON 2827 FORT MISSOULA ROAD MISSOULA MT 59804 167760436 0 X WWW.COMMUNITYMED.ORG X 1948 MT YOUR HEALTH - OUR COMMITEMENT TO YOU, FROM DAY ONE. 12 11 1393 131 2704763 -729352 1504029 1075030 148440839 156421696 498118 715839 2292684 8780714 152735670 166993279 147928 193440 0 0 71932249 76495493 0 0 2264 72330762 83990426 144410939 160679359 8324731 6313920 149194755 153399701 61708913 60360743 87485842 93038958 YOUR HEALTH - OUR COMMITMENT TO YOU, FROM DAY ONE. 0 0 126211886 193440 156421696 CMC PROVIDES DAILY PATIENT SERVICES, PROFESSIONAL AND TECHNICAL SERVICES, AND REHABILITATION SERVICES FOR PATIENT CARE. 5,175 INPATIENTS ARE ADMITTED TO CMC EACH YEAR. 133,150 OUTPATIENT SERVICES ARE PROVIDED ANNUALLY. 101,675 VISITS ARE MADE TO OUR PHYSICIANS. THE AMOUNT OF CHARGES FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER THE HOSPITAL'S CHARITY POLICY AGGREGATED APPROXIMATELY $4,462,592 FOR THE YEAR ENDED JUNE 30, 2013. 126211886 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 164 0 1393 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X DAVID RICHHART 4063274004 2827 FORT MISSOULA ROAD MISSOULA MT 59804 SCOTT STEARNS 1.50 X X 0 0 0 SCOTT HACKER 1.50 X X 0 0 0 JAN PARKS 1.50 X X 0 0 0 JOHN VANSTRYDONCK 1.50 X X 0 0 0 TANYA ASK 1.50 X 0 0 0 FRANK D'ANGELO 1.50 X 0 0 0 MARK GARNAAS MD 1.50 X 0 0 0 BILL JOHNSTON 1.50 X 0 0 0 ROBERT PHILLIPS 1.50 X 0 0 0 SUZANNE PETERSON 1.50 X 0 0 0 THOMAS LOWDER MD 40.00 X 175325 0 27984 MICHAEL STEWART MD 1.50 X 0 0 0 RON PREMUROSO 1.50 X 0 0 0 ROGER MUNRO 1.50 X 0 0 0 STEVE CARLSON 40.00 X 377833 0 33551 STAN MOSER 40.00 X 89971 0 0 DAVID LECHNER 40.00 X 235454 0 17924 DAVID RICHHART 40.00 X 192309 0 18965 JONATHAN WEISUL 40.00 X 294015 0 29473 DAVID JINICH MD 40.00 X 706473 0 14149 GREGORY UTTER MD 40.00 X 384025 0 42003 ELIZABETH SUH MD 40.00 X 289445 0 5047 BONNIE STEPHENS MD 40.00 X 280342 0 28167 PHILLIP HOLMAN MD 40.00 X 275806 0 33767 3300998 0 251030 83 0 1 0 MT HEART ANGIO LAB LLC 2827 FORT MISSOULA ROAD MISSOULA MT 59804 CARDIOLOGY SERVICES 1837082 MT CANCER SPECIALISTS PO BOX 7877 MISSOULA MT 59807 ONCOLOGY SERVICES 1826338 BILLINGS CLINIC PO BOX 30977 BILLINGS MT 59107 MEDICAL SERVICES 1267250 SOUND INPATIENT PO BOX 742936 LOS ANGELES CA 90074 HOSPITALIST 964640 MAYO COLLABORATIVE PO BOX 9146 MINNEAPOLIS MN 55480 LAB SERVICES 641288 25 905432 145000 24598 1075030 NET PATIENT REVENUE 621500 153108767 150404004 2704763 JV ANCILLARY REVENUE 621500 3396662 3396662 HEART LAB REVENUE 621500 -83733 -83733 156421696 653066 653066 540695 0 540695 540695 540695 829930 767157 62773 62773 62773 MISCELLANEOUS REVENUE 900099 5967518 5967518 MEANINGFUL USE REVENUE 900099 2272501 2272501 8240019 166993279 153716933 2704763 9496553 X 193440 193440 1543988 1543988 60456888 47217494 13239394 2222957 1697869 525088 7933908 6905783 1028125 4337752 3313125 1024627 91342 91342 78038 78038 21431251 15981708 5449098 445 3076494 1455911 1620583 2864114 1222301 1640130 1683 677016 413056 263960 1490743 1490743 8377011 8350351 26660 1326634 1326634 MEDICAL SUPPLIES/DRUGS 22357853 22357853 BAD DEBT 8896739 8896739 REPAIRS & MAINTENANCE 7149666 836481 6313185 LICENSE & FEES 1314498 1302045 12453 4859027 3250353 1608538 136 160679359 126211886 34465209 2264 17084983 14906384 21681565 10937099 20999168 25960108 3855003 3877121 3097534 3414286 1114186 1084495 138676742 69476606 62307258 69200136 10026066 15101689 3423001 3773064 889946 827029 4716045 4318290 149194755 153399701 17349578 20570213 30812 31932 24428532 24447509 11858882 10321822 945429 355034 7095680 4634233 61708913 60360743 X 82901610 88813900 1490082 1125361 3094150 3099697 87485842 93038958 149194755 153399701 X 6313920 -368237 -392567 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7426 7426 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: COMMUNITY MEDICAL CENTER PAYS DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND MONTANA HOSPITAL ASSOCIATION. THESE ORGANIZATION PARTICIPATE IN LOBBYING ACTIVITIES. 3822091 11831 202604 943702 3092824 3756462 41273 24356 3822091 3054980 49499 651983 3756462 2356624 38678 659678 3054980 2952845 11855 -608076 2356624 0.00000 1.00000 0.00000 0 1 1 209682 209682 62536099 26989018 35547081 1333889 336075 997814 68051604 42151513 25900091 6545468 6545468 69200136 MORTGAGE BACKED GOVERNMENT SECURITIES 15101689 F 15101689 THIRD PARTY PAYABLE 4634233 4634233 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE CMC FOUNDATION AND THE INCOME EARNED ON THESE FUNDS ARE DISTRIBUTED TO THE HOSPITAL TO COMPLY WITH THE PURPOSES SPECIFIED BY THE DONOR. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. 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 HOSPITAL'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE HOSPITAL IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE TAX RETURNS FOR THE YEARS ENDED 2010 TO 2012 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. 1 1 X 1 X 1 X 1 1 0 1 1 2200058 22500 2177558 0.01360 27508720 22840083 4668637 0.02910 29708778 22862583 6846195 0.04270 1465232 1465232 0.00910 319476 319476 0.00200 22329750 13476873 8852877 0.05510 201421 201421 0.00130 24315879 13476873 10839006 0.06750 54024657 36339456 17685201 0.11020 20000 20000 0.00010 3000 3000 0.00000 23000 23000 0.00010 1 8896739 35000 24623250 32594693 -7971443 X 1 1 1 1 COMMUNITY MEDICAL CENTER

2827 FORT MISSOULA ROAD MISSOULA MT 59804

X X X COMMUNITY MEDICAL CENTER 1 1 X X X X X X X X X 11 1 1 1 X X X X X X X X X X X 1 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X X X 1 0 X X X X X 1 X X 0 0 20 CPG MISSOULA VALLEY PEDIATRICS (MVP)

2835 FORT MISSOULA ROAD SUITE 201 205 MISSOULA MT 59804

PEDIATRICS CMC REHABILITATION PHYSICIANS

2827 FORT MISSOULA ROAD MISSOULA MT 59804

PHYSIATRISTS, FAMILY NURSE PRACTIONER, PY CPG PARKSIDE COMMUNITY FAMILY CARE

2831 FORT MISSOULA ROAD SUITE 146 MISSOULA MT 59804

FAMILY PRACTICE ROCKY MOUNTAIN NEONATOLOGY (RMN)

2827 FORT MISSOULA ROAD MISSOULA MT 59804

NEONATOLOGY ROCKY MOUNTAIN PERINATAL ASSOCIATES

2825 FORT MISSOULA ROAD SUITE 217 MISSOULA MT 59804

PERINATOLOGY CPG STEVENSVILLE CMC (SCMC)

3800 EASTSIDE HIGHWAY STEVENSVILLE MT 59870

INTERNAL MEDICINE, FAMILY PRACTICE WELLCARE

2825 FORT MISSOULA ROAD SUITE 203 MISSOULA MT 59804

INDEPENDENT MEDICAL EXAMS FOR WORKERS' COMP CPG DIABETES & ENDOCRINOLOGY ASSOCIATES

1211 S RESERVE ST STE 201 MISSOULA MT 59801

ENDOCRINOLOGY CPG DIABETES & NUTRITION CENTER

1211 S RESERVE ST STE 202 MISSOULA MT 59804

PUMP EDUCATOR, DIETITIAN, DIABETES EDUCATION MOUNTAIN VIEW FAMILY MEDICINE

2835 FORT MISSOULA ROAD SUITE 101 MISSOULA MT 59804

FAMILY PRACTICE CPG ON NORTH RESERVE

2230 NORTH RESERVE STREET MISSOULA MT 59801

FAMILY PRACTICE/OPEN ACCESS WALK-IN CARE CPG ON SOUTH RESERVE

1211 RESERVE ST SOUTH SUITE 101 MISSOULA MT 59801

FAMILY PRACTICE/RHEUMATOLOGY CPG COUMADIN CLINIC

2825 FORT MISSOULA ROAD STE 115 MISSOULA MT 59804

COUMADIN CPG CARDIOLOGYGENERAL & VASCULAR SURGER

2831 FORT MISSOULA RD STE 102 MISSOULA MT 59804

CARDIOLOGY, GENERAL & VASCULAR SURGERY CPG NORTH PRIMARY CARE

2230 NORTH RESERVE STREET MISSOULA MT 59808

INTERNAL MEDICINE MONTANA BREAST HEALTH CENTER

2827 FORT MISSOULA ROAD MISSOULA MT 59804

BREAST HEALTH CPG OBGYN

2825 FORT MISSOULA ROAD STE 217 MISSOULA MT 59804

OB/GYN CPG NEUROSURGERY & CPG NEUROBEHAIVORAL

2825 FORT MISSOULA ROAD STE 317 MISSOULA MT 59804

NEUROLOGY CPG THORACIC SURGERY

2835 FORT MISSOULA ROAD STE 204 MISSOULA MT 59804

THORACIC SURGERY COMMUNITY BRIDGES & WORCCENTER

2685 PALMER ST SUITE D MISSOULA MT 59801

BRAIN INJURY REHABILITATION PART I, LINE 7: THE COSTING METHOD USED WAS THE COST TO CHARGE RATIO DERIVED FROM USING WORKSHEET 2. PART I, LINE 7G: $5,970,507 OF SUBSIDIZED HEALTH SERVICES IS ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, L7 COL(F): WHEN CALCULATING CHARITY-CARE PERCENTAGE OF TOTAL EXPENSES (SCHEDULE H, PART I, LINE 7, COLUMN F), THE HOSPITAL ELIMINATED $8,896,739 OF BAD DEBT EXPENSE. PART II: CMC INVESTS IN MISSOULA AND THE SURROUNDING AREA THROUGH MULTIPLE AVENUES. AS A KEY PARTNER OF THE MISSOULA ECONOMIC PROJECT (MEP), CMC HELPS MEP CREATE A PROGRESSIVE BUSINESS DEVELOPMENT AND RECRUITMENT PROGRAM FOR THE CITY OF MISSOULA. WE BELIEVE THAT A STRONG BUSINESS COMMUNITY CREATES A VIBRANT CITY THAT CAN BE SUPPORTED BY NON-PROFIT HEALTHCARE ORGANIZATIONS, SUCH AS CMC. IN ADDITION, OUR PARTICIPATION IN EMERGENCY PREPAREDNESS IN PARTNERSHIP WITH OTHER HOSPITALS, FIRE, POLICE, AND THE CITY/COUNTY GOVERNMENT STRENGTHENS OUR ABILITY TO RESPOND EFFICIENTLY AND QUICKLY TO ANY EMERGENCY WITHIN THE AREA. AS MISSOULA CHAMBER OF COMMERCE MEMBERS, WE SUPPORT OUR BUSINESS COMMUNITY BY SPONSORING AT LEAST ONE PARTICIPANT FROM CMC IN THE LEADERSHIP MISSOULA PROGRAM ANNUALLY. THIS PROGRAM CREATES AMBASSADORS OF CMC EMPLOYEES FOR THE LARGER COMMUNITY. PART III, LINE 4: PART III, LINE 3 - THE AMOUNT OF BAD DEBT EXPENSE THAT IS ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE IS BASED ON HISTORY AND THE JUDGMENT OF THE DIRECTOR OF PATIENT ACCOUNTS.PART III, LINE 4 - 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 PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: ONE HUNDRED PERCENT OF THIS SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT. THIS AMOUNT IS CONSIDERED TO BE COMMUNITY BENEFIT FOR THE FOLLOWING REASONS: IN OUR COMMUNITY MEDICARE HAS THE LOWEST REIMBURSEMENT RATE OF ALL PAYERS. WE DO NOT BELIEVE OUR MEDICARE SHORTFALL TO BE FROM ANY SORT OF DEFICIENCIES IN THE EFFICIENCY OF OPERATIONS OR LOW PATIENT VOLUMES. THE AMOUNTS SHOWN ARE CALCULATED BY UTILIZING THE INCOME AND EXPENSES AS CALCULATED BY THE MEDICARE COST REPORT LESS ANY AMOUNTS THAT ARE ALREADY INCLUDED IN THE SUBSIDIZED HEALTH EXPENSES. PART III, LINE 9B: PATIENTS RECEIVE INFORMATION AT THE TIME OF REGISTRATION REGARDING FINANCIAL ASSISTANCE BOTH FOR SELF PAY AND BALANCE AFTER INSURANCE. ALL SELF PAY PATIENTS ARE SCREENED FOR ELIGIBILITY FOR FEDERAL, STATE AND LOCAL PROGRAMS BY THE MASH PROGRAMS, AND IF NO ELIGIBILITY EXISTS, PATIENTS ARE FURTHER SCREENED FOR HOSPITAL FINANCIAL ASSISTANCE. ADDITIONALLY, PATIENTS RECEIVE INFORMATION REGARDING FINANCIAL ASSISTANCE IN THEIR BILLING STATEMENTS AS WELL AS VERBALLY WHEN FOLLOW UP CALLS ARE MADE ON ANY PATIENT BALANCE. PATIENTS WHO QUALIFY FOR CHARITY CARE RECEIVE AN ADJUSTMENT ON THE BALANCE OF THEIR ACCOUNT CORRESPONDING WITH THE APPROPRIATE REDUCTION ACCORDING TO POLICY. REMAINING BALANCES, IF ANY, ARE COLLECTED EITHER IN FULL OR BY PAYMENT PLAN, OR IN THE CASE OF NON-PAYMENT MAY HAVE THE ADJUSTED BALANCE ASSIGNED TO AN OUTSIDE AGENCY FOR RESOLUTION. COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 3: NUMEROUS STAKEHOLDERS FROM THE LARGER COMMUNITY WERE INVOLVED IN THE CREATION OF THE CHNA, INCLUDING; MISSOULA AGING SERVICES, INDIAN HEALTH SERVICE, UNIVERSITY OF MONTANA, MISSOULA YMCA, MISSOULA UNITED WAY, AND MISSOULA COUNTY PARKS & RECREATION. COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 4: MISSOULA CITY-COUNTY HEALTH DEPARTMENTPARTNERSHIP HEALTH CENTERPROVIDENCE ST. PATRICK HOSPITAL COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 5C: THE CHNA WAS POSTED ON THE MISSOULA CITY-COUNTY HEALTH DEPARTMENT WEBSITE, THE COMMUNITY MEDICAL CENTER WEBSITE, AND THE PROVIDENCE ST. PATRICK HOSPITAL WEBSITE, AS WELL AS BEING APPROVED BY THE BOARD OF HEALTH. COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 14G: CUSTOMER SERVICE PHONE, CASHIER'S WINDOW, DURING SCREENING FOR OTHER SOURCES OF PAYMENT, COLLECTION AGENCIES, CMC REPRESENTATIVES. COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 18E: NOTIFY PATIENTS OF AVAILABILITY OF CHARITY WHEN MAKING PAYMENT ARRANGEMENTS. COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 20D: THE MINIMUM DISCOUNT ALLOWED FOR INDIVIDUALS ELIGBLE UNDER THIS POLICY WILL MEET OR EXCEED THE AVERAGE DISCOUNT RATE (CALCULATED ANNUALLY) BY COMMERCIAL PAYORS. IN THE CASE OF CATASTROPHIC EVENTS, CMC USES MEDICARE RATES TO DETERMINE THE MAXIMUM AMOUNTS TO BE CHARGED TO FAP ELIGIBLE PATIENTS. PART VI, LINE 2: CMC ASSESSES THE NEEDS OF THE COMMUNITY ALONG WITH OUR PARTNER ORGANIZATIONS AND THEN CRAFTS A RESPONSE TO THE NEEDS ASSESSMENT TO FULFILL ANY GAPS THAT ARE IDENTIFIED. COMMUNITY MEDICAL CENTER WORKS WITH SAINT PATRICK HOSPITAL AND THE MISSOULA CITY-COUNTY HEALTH DEPARTMENT TO ASSESS THE NEEDS OF THE COMMUNITY, AS WELL AS WITH OTHER NON-PROFIT ORGANIZATIONS, I.E., MISSOULA AGING SERVICES, YWCA, YMCA, POVERELLO HOMELESS SHELTER, AND UNITED WAY. PART VI, LINE 3: PATIENTS RECEIVE INFORMATION AT THE TIME OF REGISTRATION REGARDING FINANCIAL ASSISTANCE BOTH FOR SELF PAY AND BALANCE AFTER INSURANCE. ALL SELF PAY PATIENTS ARE SCREENED FOR ELIGIBILITY FOR FEDERAL, STATE AND LOCAL PROGRAMS BY THE MASH PROGRAMS, AND IF NO ELIGIBILITY EXISTS, PATIENTS ARE FURTHER SCREENED FOR HOSPITAL FINANCIAL ASSISTANCE. ADDITIONALLY, PATIENTS RECEIVE INFORMATION REGARDING FINANCIAL ASSISTANCE IN THEIR BILLING STATEMENTS AS WELL AS VERBALLY WHEN FOLLOW UP CALLS ARE MADE ON ANY PATIENT BALANCE. PART VI, LINE 4: CMC SERVES THE COMMUNITY OF MISSOULA, MT AND THE SURROUNDING COUNTIES. MONTANA IS A RURAL STATE AND THEREFORE, THERE ARE LIMITED HOSPITALS IN THE REGION. THERE ARE TWO HOSPITALS IN MISSOULA. CMC SERVES A DISPROPORTIONATE NUMBER OF LOWER INCOME INDIVIDUAL AND THEREFORE RECEIVES DSH PAYMENTS. 1 AMERICAN HEART ASSOCIATION 320 B EAST MAIN ST MISSOULA MT 59802 135613797 501(C)(3) 22083 SUPPORT OF MISSION MISSOULA ECONOMIC PARTNERSHIP PO BOX 7457 MISSOULA MT 59807 273994460 501(C)(6) 20000 SUPPORT OF MISSION CMC FOUNDATION 2827 FORT MISSOULA ROAD MISSOULA MT 29804 363627205 501(C)(3) 11500 SUPPORT OF MISSION UNITED WAY OF MISSOULA COUNTY PO BOX 7395 MISSOULA MT 59806 810287854 505(C)(3) 10305 SUPPORT OF MISSION MISSOULA FAMILY YMCA 3000 S RUSSELL ST MISSOULA MT 59801 810300829 501(C)(3) 10000 SUPPORT OF MISSION MISSOULA CHAMBER COMMERCE PO BOX 7577 MISSOULA MT 59807 810167990 501(C)(6) 7625 SUPPORT OF MISSION MISSOULA DOWNTOWN ASSOCIATION 218 EAST MAIN STREET MISSOULA MT 59802 810403474 501(C)(6) 5100 SUPPORT OF MISSION 4 3 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ONLY NONPROFIT ORGANIZATIONS ARE ELIGIBLE FOR DONATIONS FROM CMC. THEY HAVE TO IDENTIFY HOW THEIR MISSION LINKS TO CMC'S AND OUR CORE COMPETENCIES IN WOMEN'S HEALTH, PEDIATRICS, ONCOLOGY, AND REHABILITATION. ALL COMMUNITY BENEFIT APPLICATIONS AND SUPPORTING MATERIALS ARE KEPT FOR EACH GRANT GIVEN. ONCE FUNDING IS GRANTED, NO ADDITIONAL MONITORING IS PERFORMED BY CMC. X 0 0 X X X X 0 0 0 0 0 0 0 0 0 THOMAS LOWDER MD 172994 0 1750 0 581 0 2810 0 25174 0 203309 0 0 0 STEVE CARLSON 376591 0 0 0 1242 0 18131 0 15420 0 411384 0 0 0 STAN MOSER 89971 0 0 0 0 0 0 0 0 0 89971 0 0 0 DAVID LECHNER 234212 0 0 0 1242 0 3212 0 14712 0 253378 0 0 0 DAVID RICHHART 190147 0 0 0 2162 0 9119 0 9846 0 211274 0 0 0 JONATHAN WEISUL 294015 0 0 0 0 0 13251 0 16222 0 323488 0 0 0 DAVID JINICH MD 615406 0 89825 0 1242 0 5173 0 8976 0 720622 0 0 0 GREGORY UTTER MD 381703 0 0 0 2322 0 18380 0 23623 0 426028 0 0 0 ELIZABETH SUH MD 287159 0 2286 0 0 0 1356 0 3691 0 294492 0 0 0 BONNIE STEPHENS MD 279856 0 0 0 486 0 5564 0 22603 0 308509 0 0 0 PHILLIP HOLMAN MD 273351 0 0 0 2455 0 9324 0 24443 0 309573 0 0 0 PART I, LINE 1A CMC PAID COUNTRY CLUB DUES ON BEHALF OF STEVE CARLSON, CEO IN THE AMOUNT OF $2,837. THIS AMOUNT WAS NOT INCLUDED IN STEVE'S TAXABLE COMPENSATION. A MONTANA FACILITY FINANCE AUTHORITY 364615155 612043JA3 2010-12-29 24400067 CONSTRUCTION/FACILITY EXPANSION OF WOMEN'S, NEWBORN CARE, & ONCOLOGY CENTER 0 0 0 B MONTANA FACILITY FINANCE AUTHORITY 364615155 2010-06-29 14525000 REFINANCE 1988, 1996, AND 2001 BONDS 0 0 0 A 24146299 2141930 2254310 565765 15777834 3390922 0 0 0 1 B 12740000 14345948 178052 2001 0 1 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 A 0 B 0 SCHEDULE K, PART II, LINE 3 TOTAL PROCEEDS OF ISSUE TOTAL PROCEEDS OF $24,146,299 ON PART II, LINE 3 DOES NOT EQUAL THE ISSUE PRICE OF $24,400,061 INCLUDED IN PART I, LINE A, COLUMN E. THE DIFFERENCE OF $253,768 IS EQUAL TO THE UNDERWRITERS' DISCOUNTS. TOTAL PROCEEDS OF $14,345,948 ON PART II, LINE 3 DOES NOT EQUAL THE ISSUE PRICE OF $14,524,000 INCLUDED IN PART I, LINE A, COLUMN E. THE DIFFERENCE OF $178,052 IS EQUAL TO THE BOND ISSUANCE COSTS. FORM 990, PART VI, SECTION A, LINE 1 THE ROLE OF THE EXECUTIVE COMMITTEE IS TO TRANSACT THE BUSINESS OF THE COMMUNITY MEDICAL CENTER BOARD OF DIRECTORS IN THE INTERIM BETWEEN MEETINGS OF THE FULL BOARD, WHEN A MEETING OF THE FULL BOARD IS NOT FEASIBLE. THEIR RESPONSIBILITIES INCLUDE: - ACT ON MATTERS THAT CANNOT REASONABLY WAIT ACTION BY THE FULL BOARD. - ACT ON OTHER MATTERS DELEGATED TO THE EXECUTIVE COMMITTEE BY THE BOARD. - REPORT ACTIONS AT THE NEXT MEETING OF THE BOARD FOR RATIFICATION. - FUNCTION AS AN ADVISOR TO THE PRESIDENT/CEO ON SENSITIVE TOPICS. - PROVIDE INPUT INTO THE CONTENT AND STRUCTURING OF THE BOARD AGENDA. - CONDUCT THE EVALUATION AND SET THE SALARY OF THE PRESIDENT/CEO. THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE OFFICERS OF THE BOARD AND ONE ADDITIONAL BOARD MEMBER AT LARGE. THE PRESIDENT/CEO SHALL BE AN EX OFFICIO MEMBER WITHOUT VOTE. THE CHAIR OF THE BOARD APPOINTS THE COMMITTEE MEMBERS ANNUALLY, TO COINCIDE WITH THE ELECTION OF OFFICERS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND RELATED SCHEDULES WILL BE GIVEN TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C IN THE BEGINNING OF EACH CALENDAR YEAR, THE BOARD IS REQUIRED TO COMPLETE AND SIGN A CONFLICT OF INTEREST FORM THAT SPECIFICALLY ASKS ABOUT OUTSIDE INTERESTS, OUTSIDE ACTIVITIES, GIFTS, GRATUITIES, AND ENTERTAINMENT, AND INSIDE INFORMATION AND OTHER INTEREST. ON THIS SAME FORM, BOARD MEMBERS MUST ALSO CERTIFY THAT THEY HAVE A CONTINUING RESPONSIBILITY TO OBSERVE AND APPLY THE PROVISIONS OF THE POLICY. THIS CERTIFICATION REQUIRES THAT THEY UPDATE THEIR CONFLICT OF INTEREST FORM SHOULD ANY NEW CONFLICTS DEVELOP. ANY BOARD MEMBER WITH A CONFLICT OF INTEREST MAY NOT VOTE, INFLUENCE, OR PARTICIPATE IN ANY WAY ON ANY MATTER THAT THEY, OR THEIR RELATIVES, HAVE A SUBSTANTIAL INTEREST. THE ANNUAL CONFLICT OF INTEREST FORMS ARE MONITORED BY THE CEO'S ASSISTANT. FORM 990, PART VI, SECTION B, LINE 15 WE HIRED AN INDEPENDENT SERVICE (INTEGRATED HEALTHCARE STRATEGIES) TO DO AN EXECUTIVE COMPENSATION SURVEY. THIS SURVEY WAS CONDUCTED FOR THE TOP 12 COMPENSATED EMPLOYEES OF THE HOSPITAL. THE DATA WAS PRESENTED TO THE BOARD OF DIRECTORS, AND SALARY ADJUSTMENTS (IF ANY) WERE DETERMINED. THE SURVEY INCLUDED REGIONAL AND NATIONAL COMPARISONS TO INSTITUTIONS OF A SIMILAR SIZE AND REVENUE GENERATION TO MAKE THE RESULTS COMPARABLE. AS MENTIONED ABOVE, THE SAME PROCESS THAT WAS USED FOR THE CEO, WAS USED TO COMPARE THE SALARIES OF OTHER KEY EXECUTIVES. THE LAST COMPENSATION ANALYSIS WAS PERFORMED IN 2011. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, CMC'S FORM 990 IS ALSO AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 15,981,708. MANAGEMENT AND GENERAL EXPENSES 5,449,098. FUNDRAISING EXPENSES 445. TOTAL EXPENSES 21,431,251. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST OF CMC FOUNDATION -392,567. COMMUNITY MEDICAL CENTER FOUNDATION 2827 FORT MISSOULA ROAD MISSOULA MT 59804 363627205 TO PROVIDE FUNDING TO COMMUNITY MEDICAL CENTER HOSPITAL MT 501(C)(3) 7 N/A 0 MONTANA HEART ANGIO LAB LLC 2827 FORT MISSOULA ROAD MISSOULA MT 59804 810542065 CATH LAB MT COMMUNITY MEDICAL CENTER RELATED 2356353 1850933 0 0 0.92900 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 0 1 0 0 MONTANA HEART ANGIO LAB LLC A 95518 FMV MONTANA HEART ANGIO LAB LLC D 240071 FMV MONTANA HEART ANGIO LAB LLC J 95518 FMV MONTANA HEART ANGIO LAB LLC K 54748 FMV MONTANA HEART ANGIO LAB LLC L 117616 FMV MONTANA HEART ANGIO LAB LLC M 1833160 FMV MONTANA HEART ANGIO LAB LLC O 783197 FMV MONTANA HEART ANGIO LAB LLC Q 1947072 FMV