2013-11-05T13:39:48-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 470378779 THE MARY LANNING MEMORIAL HOSPITAL ASSOCIATION MARY 4024634521 715 NORTH ST JOSEPH AVE HASTINGS NE 68901 ERIC BARBER 4024634521 2013-10-30 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-03-07 17:11:31Z MARY LANNING HEALTHCARE ERIC BARBER 715 NORTH ST JOSEPH AVE HASTINGS NE 68901 122007079 0 X WWW.MARYLANNING.ORG X 1915 NE ADVANCING OUR TRADITION OF SERVICE, EDUCATION AND COMMUNITY INVOLVEMENT, MARY LANNING HEALTHCARE IS DEDICATED TO EXCELLENCE, OFFERING HOPE, HEALTH AND HEALING. 6 5 1111 162 194499 0 2473735 1531890 98090488 113975564 1609435 1475204 2550114 4113414 104723772 121096072 1083322 331620 0 0 53561201 59926430 0 0 0 47769774 54425002 102414297 114683052 2309475 6413020 138226405 152040846 56406414 57163837 81819991 94877009 X ADVANCING OUR TRADITION OF SERVICE, EDUCATION AND COMMUNITY INVOLVEMENT, MARY LANNING HEALTHCARE IS DEDICATED TO EXCELLENCE, OFFERING HOPE, HEALTH AND HEALING. 0 0 90278780 331620 117071018 MARY LANNING HEALTHCARE (MLH) PROVIDES HEALTHCARE SERVICES TO THE GENERAL PUBLIC AND OPERATES ROUTINE SERVICE BEDS, ICU BEDS, OUTPATIENT SERVICES, A HOME HEALTH PROGRAM, AND A SCHOOL OF NURSING. MLH TAKES ITS RESPONSIBILITIES FOR PROVIDING BENEFITS TO THE SURROUNDING COMMUNITIES SERIOUSLY. THIS IS DEMONSTRATED IN NUMEROUS WAYS. THE HOSPITAL ABSORBED OVER $29 MILLION IN COSTS DURING 2012. OVER $10 MILLION OF THAT AMOUNT RELATES TO CARE PROVIDED TO MEDICARE AND MEDICAID PATIENTS WITH AN ADDITIONAL $2.2 MILLION IN CARE TO THE UNINSURED IN THE FORM OF CHARITY CARE. SEVENTY-TWO (72) ADDITIONAL PROGRAMS SERVED OVER 77,000 PEOPLE. MUCH ATTENTION HAS BEEN PAID RECENTLY TO THE RESPONSIBILITIES OF TAX EXEMPT ORGANIZATIONS. FROM THE INFORMATION SUMMARIZED ABOVE, IT IS CLEAR THAT THE CONTRIBUTIONS OF THE HOSPITAL WOULD FAR EXCEED FUNDS THAT WOULD BE GENERATED BY A CORPORATE TAX STRUCTURE. 90278780 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 0 1 0 1 60 0 1 1111 1 1 1 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X SHAWN NORDBY 4024615344 715 N ST JOSEPH AVE HASTINGS NE 68901 X JEFF S ANDERSON 1.00 0.00 X X 0 0 0 MICHELE BEVER 1.00 0.00 X X 0 0 0 CLARENCE GARY ANDERSON 1.00 40.00 X 0 102744 16608 DENNIS KRIENERT 1.00 0.00 X 0 0 0 CALVIN JOHNSON 1.00 0.00 X 0 0 0 MIKE ALLEN 1.00 0.00 X 0 0 0 PRADIPTA CHAUDHURI MD THRU 1012 1.00 0.00 X 0 0 0 BRADLEY NEET 40.00 0.00 X 297883 0 30148 MICHAEL SKOCH MD 40.00 0.00 X 420324 0 21607 RONDA EHLY 40.00 0.00 X 164554 0 26065 SHAWN NORDBY 40.00 0.00 X 121737 0 19611 LEON DAVIS 40.00 0.00 X 210941 0 9935 RENEE SIDLEY 40.00 0.00 X 153891 0 16847 BRUCE CUTRIGHT 40.00 0.00 X 157985 0 10495 MARK CALLAHAN 40.00 0.00 X 180775 0 25349 SHAWN RIGGS 40.00 0.00 X 120514 0 23720 JAMES NEALON 40.00 0.00 X 505489 0 30602 JOHN BECK 40.00 0.00 X 411419 0 30710 KALPESH GANATRA 40.00 0.00 X 734269 0 45710 DENNIS HATCH 40.00 0.00 X 334059 0 37598 MATTHEW STRITT 40.00 0.00 X 439595 0 34523 4253435 102744 379528 37 0 1 0 MCKESSON INFORMATION BOX 98347 CHICAGO IL 60693 SOFTWARE SUPPORT 1021274 SS PSYCHIATRY GROUP 4110 HARGORD STREET GRAND ISLAND NE 68803 PHYSICIAN COVERAGE 993462 SIEMENS MEDICAL SOLUTIONS DEPT CH 14195 PALATINE IL 60055 SOFTWARE SUPPORT 874677 GE HEALTHCARE PO BOX 96483 CHICAGO IL 60693 SOFTWARE SUPPORT 730655 FARRIS CONSTRUCTION PO BOX 2046 HASTINGS NE 68902 GENERAL CONTRACTOR 646113 99 632 1531258 1531890 ALL OTHER PATIENT REVE 621300 70426801 70426801 NET MEDICARE REVENUE 621300 38003568 38003568 NET MEDICAID REVENUE 621300 5545195 5545195 113975564 8192 8192 1065710 1065710 301629 2392 299237 299237 299237 431153 658456 0 688307 431153 -29851 401302 -29851 431153 196302 220308 -24006 -24006 MISCELLANEOUS 900099 3125305 3125305 CAFETERIA 722210 518379 518379 194499 194499 3838183 121096072 117071018 194499 2298665 331620 331620 2299682 2299682 43755740 37547347 6208393 3482274 3008003 474271 7275447 6284562 990885 3113287 2594466 518821 69199 69199 124440 124440 107175 107175 2660537 2660537 2986308 1181616 1804692 1107520 1107520 277602 234722 42880 353160 210074 143086 1502498 1502498 8536176 8234156 302020 905757 408928 496829 MEDICAL SUPPLIES 17642851 17590514 52337 CONTRACTED SERVICES 10026950 5538296 4488654 BAD DEBT EXPENSE 5905448 5905448 REPAIRS 1744901 1620811 124090 474480 223110 251370 114683052 90278780 24404272 0 3486 4488544 5743936 9861799 14879823 584309 865590 2403869 2635092 1173074 1142319 151678342 83895453 67568044 67782889 27451673 29973868 23597435 27218168 0 761157 1097658 1034518 138226405 152040846 10973989 11888042 28530000 27185000 1732665 16902425 16358130 56406414 57163837 X 58800159 68691762 2950416 3020527 20069416 23164720 81819991 94877009 138226405 152040846 X 6413020 2074666 4569332 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 22384 22384 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF DUES PAID TO AHA AND NHA IS FOR LOBBYING PURPOSES AND 100% OF DUES PAID TO NABHO IS FOR LOBBYING ACTIVITIES. IN ADDITION, $6,500 PAID TO RURAL REFERRAL CENTER / SOLE COMMUNITY HOSPITAL COALITION SUPPORTS LOBBYING ACTIVITY CONDUCTED BY THAT ORGANIZATION. 20694745 3205121 23899866 17842614 3119278 267147 20694745 15975895 87241 1850255 70777 17842614 14499723 67547 1873061 464436 15975895 13467863 37074 994786 14499723 0.00000 1.00000 0.00000 0 1 1 4301988 4301988 86163981 41630611 44533370 57836525 42264842 15571683 3375848 3375848 67782889 STUDENT LOAN AND RESTRICTED FUNDS 658176 F JOINT VENTURES 298559 F BENEFICIAL INTEREST IN FOUNDATION 3609713 F BENEFICIAL INTEREST IN TRUST 22651720 F 27218168 THIRD PARTY REIMBURSEMENT CONTRACTS 3107640 LIABILITY FOR PENSION BENEFITS 13250490 16358130 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TEMPORARILY RESTRICTED FUNDS ARE HELD FOR CAPITAL ACQUISITION, SCHOLARSHIPS, EDUCATION AND COMMUNITY HEALTH CARE. PERMANENTLY RESTRICTED FUND ASSETS ARE HELD IN PERPETUITY WITH THE INCOME USED FOR HOSPITAL OPERATIONS, SCHOLARSHIPS AND RESEARCH. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE OR LOCAL AUTHORITIES FOR YEARS BEFORE 2009. PART V, LINE 3A(II): MARY LANNING HEALTHCARE FOUNDATION AND MARY LANNING HOSPITAL TRUST HOLD ENDOWMENT FUNDS RESTRICTED TO DISTRIBUTION TO MARY LANNING HEALTHCARE. THESE FUNDS ARE REFLECTED ON MARY LANNING HEALTHCARE'S BALANCE SHEET IN "INVESTMENTS - OTHER SECURITIES" AND ARE SHOWN ON SCHEDULE D, PART VIII. THESE FUNDS ARE NOT UNDER THE CONTROL OF MARY LANNING HEALTHCARE. 1 1 1 X 125.000000000000 1 X 1 1 1 0 1 1 2238886 2238886 0.02060 11112402 6093528 5018874 0.04610 13351288 6093528 7257760 0.06670 1072984 1072984 0.00990 498243 498243 0.00460 259557 259557 0.00240 156265 156265 0.00140 1987049 1987049 0.01830 15338337 6093528 9244809 0.08500 2111 2111 0.00000 4961 4961 0.00000 1327 1327 0.00000 8399 8399 1 5905448 24740968 35101265 -10360297 X 1 1 1 1 MARY LANNING HEALTHCARE

715 NORTH ST JOSEPH AVENUE HASTINGS NE 68901

X X X X MARY LANNING HEALTHCARE 1 1 X X X X X X X X 12 1 1 1 X X X X X X X X X X 1 0 1 1 125.000000000000 1 200.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 10 LANNING CENTER

815 S BURLINGTON AVENUE HASTINGS NE 68901

OUTPATIENT CLINIC MOSCATI

223 E 14TH STREET STE 100 HASTINGS NE 68901

OUTPATIENT CLINIC HASTINGS PULMONARY

715 N KANSAS AVENUE STE 203 HASTINGS NE 68901

OUTPATIENT CLINIC HASTINGS FAMILY PRACTICE

606 N MINNESOTA HASTINGS NE 68901

OUTPATIENT CLINIC SUTTON MEDICAL CLINIC

301 S WAY SUTTON NE 68979

OUTPATIENT CLINIC BLUE HILL CLINIC

102 N PINE STREET BLUE HILL NE 68930

OUTPATIENT CLINIC COMMUNITY HEALTH CENTER

715 N KANSAS AVENUE HASTINGS NE 68901

OUTPATIENT CLINIC CENTRAL NE INFECTIOUS DISEASE

715 N KANSAS AVENUE HASTINGS NE 68901

OUTPATIENT CLINIC CENTRAL NE GENERAL SURGERY

715 N KANSAS AVENUE HASTINGS NE 68901

OUTPATIENT CLINIC EDGAR CLINIC

315 N C STREET EDGAR NE 68944

OUTPATIENT CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS A COST-TO-CHARGE RATIO. THE RATIO WAS DERIVED FROM WORKSHEET 2. PART I, L7 COL(F): BAD DEBT EXPENSE IS $5,905,448. PART II: MLH PARTICIPATES IN NEBRASKA HEALTH INFORMATION INITIATIVE WHICH ALLOWS PHYSICIANS TO VIEW THE ENTIRE RECORD OF A PATIENT. THIS BENEFITS THE PATIENT BECAUSE THE DOCTOR SEES THEIR ENTIRE HISTORY INSTEAD OF JUST THE ILLNESS OR INJURY FOR WHICH THEY ARE CURRENTLY BEING TREATED. PART III, LINE 4: THERE IS NO FOOTNOTE IN THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT ACCOUNTS RECEIVABLES, NET":THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. 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. PATIENT RECEIVABLES ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "NET PATIENT SERVICE REVENUE":THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYERS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS 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 PAYERS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYERS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "CHARITY CARE":THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE CONSOLIDATED STATEMENTS OF OPERATIONS. PART III, LINE 8: FOR-PROFIT SPECIALITY HOSPITALS HAVE BEEN CARVING OUT CERTAIN HIGH-MARGIN SERVICES, LEAVING GENERAL ACUTE CARE HOSPITALS WITH LOWER-MARGIN MEDICARE SERVICES. THIS INDICATES THAT MEDICARE LOSSES CAN BE A RESULT OF RENDERING THESE LOWER-MARGIN SERVICES RATHER THAN INEFFICIENT OPERATIONS. PART III, LINE 9B: ACCOUNTS WILL BE SCREENED FOR APPROPRIATE REFERRAL TO FINANCIAL ASSISTANCE VS. BAD DEBT WRITE OFF DURING THE COLLECTION PROCESS. THE FINANCIAL ASSISTANCE POLICY DOES INCLUDE PROVISION FOR IMPLIED CHARITY CARE IF THERE IS SUFFICIENT KNOWLEDGE TO DETERMINE THAT THE PATIENT MEETS THE QUALIFYING FACTORS OF THE PROGRAM. MARY LANNING HEALTHCARE PART V, SECTION B, LINE 3: MARY LANNING PARTNERED WITH MULTIPLE ENTITIES TO COMPLETE THE NEEDS ASSESSMENT. THE SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT (SHDHD) WAS THE PRIMARY PARTNER AND CONDUCTED THE NEEDS ASSESSMENT THROUGH MAPP PROCESS. OTHER MEMBERS OF THE CORE TEAM INCLUDED REPRESENTATIVES FROM BRODSTONE MEMORIAL HOSPITAL, WEBSTER COUNTY COMMUNITY HOSPITAL, THE CLAY COUNTY HEALTH DEPARTMENT AND A MEMBER OF THE SHDHD BOARD OF HEALTH. CORE TEAM MEMBERS SERVED AS THE PLANNING COMMITTEE AND ASSISTED WITH THE IMPLEMENTATION OF THE ASSESSMENT AND THE IDENTIFICATION OF STAKEHOLDERS AS WELL AS PROVIDING IN-KIND AND MONETARY RESOURCES. OTHER PARTNERS INCLUDED THE CDC (FIELD TEST SITE FOR THE LOCAL PUBLIC HEALTH SYSTEM PERFORMANCE ASSESSMENT) AND THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES WHO COLLECTED THE DATA FOR THE COMMUNITY THEMES AND STRENGTHS SURVEY. 70 COMMUNITY STAKEHOLDERS ALSO PARTICIPATED IN THE NEEDS ASSESSMENT PROCESS. MARY LANNING HEALTHCARE PART V, SECTION B, LINE 4: MEMBERS OF THE CORE TEAM INCLUDED REPRESENTATIVES FROM BRODSTONE MEMORIAL HOSPITAL AND WEBSTER COUNTY COMMUNITY HOSPITAL. MARY LANNING HEALTHCARE PART V, SECTION B, LINE 14G: THE FULL POLICY IS AVAILABLE UPON REQUEST FREE OF CHARGE. A SUMMARY OF THE POLICY AND CONTACT INFORMATION IS POSTED ON MARY LANNING HEALTHCARE'S WEBSITE, PRINTED ON BILLING STATEMENTS, POSTED IN ALL ADMISSION AREAS AND PROVIDED IN WRITING TO ALL PATIENTS UPON CHECK IN. PART VI, LINE 2: A NEEDS ASSESSMENT WAS CONDUCTED IN 2012 IN PARTNERSHIP WITH SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT UTILIZING THE MAPP PROCESS. SOUTH HEARTLAND AND MARY LANNING STAFF PARTNERED WITH OUR COMMUNITY STAKEHOLDERS TO DEFINE THE PRIORITY COMMUNITY NEEDS AND DEVELOP AN ACTION PLANS FROM THE ASSESSMENT DATA. PART VI, LINE 3: MLH INFORMS AND EDUCATES PATIENTS BY POSTING SIGNS IN ALL ADMISSION AREAS AND PATIENT ROOMS. BROCHURES ARE AVAILABLE IN ADMISSION AREAS. ALL NON-INSURED INPATIENTS ARE PERSONALLY VISITED AND PATIENTS MAY HAVE DISCUSSIONS WITH A FINANICAL COUNSELOR AT ANYTIME DURING THE BILLING/COLLECTION PROCESS. PART VI, LINE 4: MLH'S PRIMARY SERVICE AREA IS ADAMS COUNTY WITH A SECONDARY AREA INCLUDING MERRICK, HALL, HAMILTON, KEARNEY, CLAY, FRANKLIN, WEBSTER, AND NUCKOLLS COUNTIES. THE ESTIMATED POPULATION OF ADAMS COUNTY IS 35,000 AND THE SECONDARY SERVICE AREA IS 93,000. ADAMS COUNTY IS 563 SQ. MILES. FIFTEEN PERCENT OF THE POPULATION IN ADAMS COUNTY IS MEDICARE AGE OR OLDER. PART VI, LINE 5: MARY LANNING CURRENTLY PROMOTES HEALTH IN THE COMMUNITY THROUGH OUTREACH TO A WIDE VARIETY OF COMMUNITY ORGANIZATIONS. MUCH FOCUS IS ALREADY PLACED ON THE FIVE PRIORITY NEED AREAS IDENTIFIED IN THE CHNA. MANY DEPARTMENTS WITHIN MARY LANNING PARTICIPATE IN COMMUNITY COALITIONS, PROVIDE OUTREACH TO WORKSITES AND COMMUNITY MEMBERS INCLUDING MINORITIES AND LOW INCOME GROUPS, EDUCATE AND PROVIDE LOW COST OR NO COST SCREENINGS AND CARE. PART VI, LINE 6: NOT APPLICABLE 1 MARY LANNING HEALTHCARE FOUNDATION 715 NORTH ST JOSEPH AVENUE HASTINGS NE 68901 470800042 501(C)(3) 306620 TO ASSIST WITH THE OPERATING COSTS OF FUNDRAISING. ADAMS COUNTY CLERK 500 WEST 4TH STREET HASTINGS NE 68901 476006427 501(C)(1) 25000 TO ASSIST WITH OPERATING COSTS OF THE AMBULANCE SERVICE. 1 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: MARY LANNING HEALTHCARE ONLY MAKES CONTRIBUTIONS AND GRANTS TO CHARITABLE OR GOVERNMENTAL TAX EXEMPT ENTITIES. THE HOSPITAL VERIFIES THE TAX EXEMPT STATUS OF THE GRANT RECIPIENTS PRIOR TO MAKING THE GRANT. TERMS OF THE GRANT STATE THAT THE FUNDS ARE ONLY TO BE USED FOR CHARITABLE PURPOSES. X X 0 0 X X X 1 0 0 0 0 0 0 0 0 BRADLEY NEET 297883 0 0 0 0 0 12500 0 17648 0 328031 0 0 0 MICHAEL SKOCH MD 389324 0 31000 0 0 0 12500 0 9107 0 441931 0 0 0 RONDA EHLY 164554 0 0 0 0 0 9025 0 17040 0 190619 0 0 0 LEON DAVIS 210941 0 0 0 0 0 8712 0 1223 0 220876 0 0 0 RENEE SIDLEY 153891 0 0 0 0 0 0 0 16847 0 170738 0 0 0 BRUCE CUTRIGHT 157985 0 0 0 0 0 8250 0 2245 0 168480 0 0 0 MARK CALLAHAN 180775 0 0 0 0 0 8250 0 17099 0 206124 0 0 0 JAMES NEALON 415802 0 89687 0 0 0 12500 0 18102 0 536091 0 0 0 JOHN BECK 326420 0 84999 0 0 0 12500 0 18210 0 442129 0 0 0 KALPESH GANATRA 502682 0 231587 0 0 0 12500 0 33210 0 779979 0 0 0 DENNIS HATCH 284006 0 50053 0 0 0 12500 0 25098 0 371657 0 0 0 MATTHEW STRITT 335454 0 104141 0 0 0 12500 0 22023 0 474118 0 0 0 PART I, LINE 1A PART I, LINE 1A: HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES: A COUNTRY CLUB MEMBERSHIP IS PROVIDED TO BRADLEY NEET, CEO, FOR PERSONAL USE. THE VALUE OF THE MEMBERSHIP WAS INCLUDED AS TAXABLE WAGES IN MR. NEET'S 2012 W-2. CHAUFFEUR: VEHICLES OWNED BY MARY LANNING HEALTHCARE AND DRIVERS EMPLOYED BY THE HOSPITAL ARE MADE AVAILABLE TO PHYSICIANS WHO CHOOSE TO USE THEM FOR TRAVEL TO CLINICS IN OTHER CITIES. SUCH TRAVEL IS STRICTLY FOR HOSPITAL BUSINESS PURPOSES, AND THE PROVISION OF CARS AND DRIVERS ENABLES THE PHYSICIANS TO PERFORM VARIOUS ADMINISTRATIVE TASKS DURING THE TRAVEL TIME. PHYSICIANS ARE NOT REQUIRED TO "ACCOUNT" TO THE HOSPITAL FOR THE NUMBER OF MILES DRIVEN, AS THE ENTIRE TRAVEL COST IS A HOSPITAL BUSINESS EXPENSE. PERSONAL SERVICES: A VEHICLE ALLOWANCE IS GIVEN MONTHLY TO BRADLEY NEET. THE ALLOWANCE WAS INCLUDED AS TAXABLE WAGES IN MR. NEET'S 2012 FORM W-2. PART I, LINE 1B: MR. NEET TURNS IN THE MONTHLY BILL FROM THE COUNTRY CLUB FOR THE MEMBERSHIP DUES. PART I, LINE 4A: BRADLEY NEET, CEO RECEIVED SEVERANCE PAYMENTS OF $91,078. A HOSPITAL AUTHORITY NO 1 OF ADAMS COUNTY NE 470762824 006060BUO 2003-10-15 3305000 RENOVATION OF LOBBY AND ELEVATORS 0 0 0 B HOSPITAL AUTHORITY NO 1 OF ADAMS COUNTY NE 470762824 006060CL9 2008-07-01 23725120 TWO ADDITIONS TO THE HOSPITAL 0 0 0 A 1760000 3350850 302565 3048285 2005 0 0 1 1 B 1790000 24173723 1752116 22421606 2011 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 1 1 0 0 0 0 0 0 SCHEDULE K, PART IV, LINE 2C: ARBITRAGE (A) ISSUER NAME: HOSP AUTHORITY NO. 1 OF ADAMS COUNTY NE DATE THE REBATE COMPUTATION WAS PERFORMED: 09/30/2008 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 WAS PROVIDED TO THE MEMBERS OF THE BOARD AND WAS REVIEWED WITH THOSE MEMBERS PRIOR TO FILING THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C EACH EMPLOYEE AND BOARD MEMBER MUST ANNUALLY FILL OUT A CONFLICT SURVEY AND SIGN A CONFLICT OF INTEREST STATEMENT. FORM 990, PART VI, SECTION B, LINE 15 AN EXECUTIVE COMPENSATION REVIEW IS PERFORMED ANNUALLY. IN 2010, THE BOARD HIRED AN INDEPENDENT CONSULTANT, GRANT THORTON, TO PERFORM A REVIEW OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS, THE CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST THROUGH MARY LANNING HEALTHCARE'S ADMINISTRATIVE OFFICES. FORM 990, PART VII, SECTION A, COLUMN B: CLARENCE (GARY) ANDERSON IS EMPLOYED BY MARY LANNING TRUST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST OF FOUNDATION 185,832. CHANGE IN BENEFICIAL INTEREST OF TRUST 3,095,309. PENSION RELATED CHANGES 1,288,191. AUDIT OF ORGANIZATION'S FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C: THE BOARD OF TRUSTEES OF THE ORGANIZATION ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. SCHOOLS CONDUCTED WITHIN MARY LANNING HEALTHCARE FORM 990, PART IV, LINE 13: FORM 990, PART IV, LINE 13 IS ANSWERED "NO" BECAUSE MARY LANNING HEALTHCARE'S PRIMARY PROGRAM SERVICE IS THE PROVISION OF MEDICAL CARE THROUGH ITS HOSPITAL. HOWEVER, IT ALSO CONDUCTS A NURSING SCHOOL IN CONJUNCTION WITH CREIGHTON UNIVERSITY AND A RADIOLOGY SCHOOL. SCHEDULE E HAS NOT BEEN PREPARED BECAUSE THE ORGANIZATION DOES NOT CHECK BOX 2, PART I OF SCHEDULE A TO INDICATE IT IS A "SCHOOL". BOTH THE NURSING SCHOOL AND THE RADIOLOGY SCHOOL ARE OPERATED ON A RACIALLY NONDISCRIMINITORY BASIS. MARY LANNING HEALTHCARE FOUNDATION 741 N DENVER AVE HASTINGS NE 68901 470800042 FUNDRAISING ACTIVITIES NE 501(C)(3) 509(A)(3) TYPE III THE MARY LANNING HOSPITAL ASSOCIATION 1 MARY LANNING HOSPITAL TRUST 122 N HASTINGS AVE HASTINGS NE 68901 476000224 INVESTMENT MANAGEMENT NE 501(C)(3) 509(A)(3) TYPE II THE MARY LANNING HOSPITAL ASSOCIATION 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 MARY LANNING HOSPITAL TRUST C 1255000 CASH TRANSFER MARY LANNING HEALTHCARE FOUNDATION B 306620 CASH TRANSFER MARY LANNING HEALTHCARE FOUNDATION C 276258 CASH TRANSFER