2013-05-15T13:55:21-05:00 2012-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2011-07-01 860208451 NORTHERN COCHISE COMMUNITY HOSPITAL INC NORT 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ROLAND KNOX 5203843541 2013-05-15 1 DAVID B BARBER CPACFE P00348638 5206248229 2011 2016-02-24 21:20:13Z ROLAND KNOX 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 17700604 0 X WWW.NCCH.COM X 1966 AZ TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 7 7 255 62 0 0 1806974 1740136 16812834 15908780 -262033 887 40503 50801 18398278 17700604 7000 7500 0 0 10600063 9312047 0 0 0 7288462 7064833 17895525 16384380 502753 1316224 7192570 7745370 5055107 4291683 2137463 3453687 TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 0 0 10003913 7500 15908780 THE HOSPITAL PROVIDES HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF AGE, RACE, OR ABILITY TO PAY. SERVICES INCLUDE, BUT ARE NOT LIMITED TO EMERGENCY ROOM, PHYSICAL THERAPY, SPEECH THERAPY, RESP THERAPY, CT SCAN, MRI, NURSING HOME SERVICES, RURAL HEALTH CLINIC, LABORATORY SERVICE, AND OTHER SERVICES. 10003913 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 48 0 1 255 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X X THE ORGANIZATION 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ANSELMO TORRES 1.00 X 0 0 0 CAROL DUNAGAN 1.00 X 0 0 0 SHIRLEY SHOTTEN 1.00 X 0 0 0 KATHY COOK 1.00 X 0 0 0 E RICHARD SINGER 1.00 X 0 0 0 STEVEN METTS 1.00 X 0 0 0 HISHAM HAMAM MD CHIEF OF STAFF 1.00 X 0 0 0 ROLAND KNOX 40.00 X 123989 0 10397 DARCY ROBERTSON 40.00 X 0 0 0 JOHN MUNSON 40.00 X 83284 0 3424 JULIE HILTON 55.00 X 114391 0 4709 HELEN ROWE 40.00 X 108897 0 7569 HENRY WEDIG 40.00 X 203118 0 25245 633679 0 51344 4 0 1 0 ELHAM MEDICAL INTERNATIONAL INC PO BOX 12578 TUCSON AZ 85732 HOSPITALIST 338800 MEDICAL DIAGNOSTIC IMAGING GROUP PO BOX 17049 PHOENIX AZ 85011 RADIOLOGY 304868 ANTHONY LLEWELLYN MD PLC 5782 PLACITA DELEITE TUCSON AZ 85750 PHYSICIAN 211437 SOUTHERN AZ EMERGENCY MEDICAL SERVICES 1020 W LAS LOMITAS RD TUCSON AZ 85704 ER SERVICES 141600 ULTRAGROUP VENTURES LLC 651 E 4TH STREET SUITE 100 CHATTANOOGA TN 37403 BEHAVIORAL HEALTH 126542 5 1576163 163735 238 1740136 PATIENT SERVICE REVENU 900099 15575259 15575259 OTHER SERVICE REVENUE 900099 333521 333521 15908780 887 887 50801 0 50801 50801 50801 17700604 15908780 0 51688 7500 7500 250834 178008 72826 7175783 5092171 2083612 220856 156727 64129 1120648 795660 324988 543926 385988 157938 88231 87418 813 142839 141524 1315 1223959 1212687 11272 57780 57780 30274 30274 35884 35884 98447 98447 728437 728437 342379 37174 305205 MATERIALS AND SUPPLIES 1146554 601046 545508 OUTSIDE SERVICES 1089020 519933 569087 RENT-EQUIPMENT 795038 692873 102165 REPAIRS AND MAINTENANCE 628639 628639 657352 95204 562148 16384380 10003913 6380467 0 1314709 661643 93620 485647 2250000 3623829 151595 156831 174799 226914 6404860 3889847 3169336 2515013 38511 75493 7192570 7745370 2312291 2548638 2148899 1573137 593917 169908 5055107 4291683 X 2071867 3397968 65596 55719 2137463 3453687 7192570 7745370 1316224 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1468611 536844 931767 311026 124802 186224 4625223 3228201 1397022 2515013 ESTIMATED AMOUNTS DUE TO THIRD PARTY PAYERS 169908 169908 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL HAS BEEN RECOGNIZED AS TAX EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES FOR INCOME TAXES SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS AND A MEASUREMENT CRITERIA FOR TAX BENEFITS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES AT JUNE 30, 2012 FOR UNCERTAIN INCOME TAX POSITIONS PURSUANT TO THE STANDARD. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT INCLUDE ANY INTEREST OR PENALTIES RELATED TO INCOME TAXES. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. 1 1 X 1 X 0 0 1 1 0 0 118088 118088 0.00850 4178021 3158362 1019659 0.07310 4296109 3158362 1137747 0.08160 4296109 3158362 1137747 0.08160 58243 40000 18243 0.00130 58243 40000 18243 0.00130 1 2116210 4538694 6228530 -1689836 X 1 0 1 1 NORTHERN COCHISE COMMUNITY HOSPITAL

901 REX ALLEN DR WILLCOX AZ 85643

X X X X NORTHERN COCHISE COMMUNITY HOSPITAL 1 1 1 100.000000000000 0 1 X X X X X 1 1 X 1 X 1 X X X 1 X 0 0 5 SULPHUR SPRINGS MEDICAL CENTER

900 W SCOTT WILLCOX AZ 85643

MEDICAL CENTER NORTHERN COCHISE NURSING HOME

901 REX ALLEN DR WILLCOX AZ 85643

NURSING HOME SUNSITES MEDICAL CENTER

223 N FRONTAGE RD PEARCE AZ 85625

MEDICAL CENTER SPECIALTY CLINICS

900 W SCOTT WILLCOX AZ 85643

CLINIC SENIOR BEHAVIORAL HEALTH CENTER

901 REX ALLEN DR WILLCOX AZ 85643

MEDICAL CENTER PART I, LINE 3C: THE ORGANIZATION PROVIDES DISCOUNTED CARE BASED ON A CASE BY CASE EVALUATION. ALL INFORMATION IS REVIEWED BY THE PFS DIRECTOR AND COMPARED WITH THE POVERTY GUIDELINES AS WELL AS ALL OUTSTANDING MEDICAL EXPENSES. OTHER FACTORS WILL CONTRIBUTE TO THE FINAL DECISION. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2429685. NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL UTILIZES THE STANDARD CHARGES THAT ARE APPLIED FOR ALL PATIENTS REGARDLESS OF PAYER. 1 SCHOLARSHIPS 7 7500 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS A SCHOLARSHIP FUND WHICH IS SEPARATE AND APART FROM THE OPERATING FUNDS AND IS USED EXCLUSIVELY FOR SCHOLARSHIP PURPOSES. THE CHIEF FINANCIAL OFFICER (CFO) OR DESIGNEE SHALL MAINTAIN FINANCIAL RECORDS OF THE SCHOLARSHIP FUND AND PROVIDE AN ANNUAL REPORT TO THE GOVERNING BOARD AS WELL AS SEMI-ANNUAL OR QUARTERLY REPORTS TO THE SCHOLARSHIP COMMITTEE. X X X X 0 0 0 1 0 1 0 0 0 HENRY WEDIG 145283 0 57835 0 0 0 4641 0 20604 0 228363 0 0 0 PART I, LINE 5 PURSUANT TO THE EMPLOYEE AGREEMENT WITH CEO, AN INCENTIVE WAS PAID BASED ON THE ORGANIZATION'S REVENUE AND EARNINGS. PART I, LINE 6 PURSUANT TO THE EMPLOYEE AGREEMENT WITH CEO, AN INCENTIVE WAS PAID BASED ON THE ORGANIZATION'S REVENUE AND EARNINGS. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED BY THE CFO AND CEO AND MADE AVAILABLE TO THE BOARD OF DIRECTORS BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM ANNUALLY. THE FORMS ARE REVIEWED BY THE COMPLIANCE OFFICER FOR POTENTIAL CONFLICTS. ANY ACTUAL CONFLICTS ARE REVIEWED BY THE BOARD OF DIRECTORS. A PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED ON AN ANNUAL BASIS BY A COMPENSATION COMMITTEE BASED ON COMPARABILITY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT OR REVIEW PROCESS DURING THE YEAR. NORTHERN COCHISE HOSPITAL DISTRICT 901 REX ALLEN DR WILCOX AZ 85643 TO ENSURE THE OPERATION OF THE HOSPITAL WITHIN THE DISTRICT AZ 170(C)(1) N/A N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NORTHERN COCHISE HOSPITAL DISTRICT C 1576163 ACTUAL CASH AMOUNT TRANSFERRED