CHEYENNE COUNTY HOSPITAL ASSOCIATION INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- CHEYENNE COUNTY HOSPITAL ASSOCIATION INC (EIN 47-0408242)
- Tax period
- 2012-01-01 to 2012-12-31
- Filed
- 2013-11-14
- IRS object ID
- 201313189349305461
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-11-14T15:03:50-06:00 | Timestamp |
| Tax Period End Date | 2012-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476097913 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 680224722 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470408242 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | CHEY | NameControl |
| Phone | 3082545825 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JASON PETIK | Name |
| Title | CEO | Title |
| Phone | 3082545825 | Phone |
| Date Signed | 2013-11-13 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BARBARA J FAJEN | Name |
| PTIN | P00400874 | PTIN |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIDNEY REGIONAL MEDICAL CENTER | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | KELLY UTLEY | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 38134703 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.SIDNEYRMC.COM | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1951 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 13 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 11 | NbrIndependentVotingMembers |
| Total Nbr Employees | 413 | TotalNbrEmployees |
| Total Nbr Volunteers | 109 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 428769 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 93508 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 29553726 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 37787380 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 63175 | InvestmentIncomePriorYear |
| Investment Income Current Year | 76507 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 89767 | OtherRevenuePriorYear |
| Other Revenue Current Year | 157073 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 30135437 | TotalRevenuePriorYear |
| Total Revenue Current Year | 38114468 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 15095069 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 19286514 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 10478230 | OtherExpensePriorYear |
| Other Expenses Current Year | 15272166 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 25573299 | TotalExpensesPriorYear |
| Total Expenses Current Year | 34558680 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 4562138 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 3555788 | RevenuesLessExpensesCY |
| Total Assets BOY | 29888648 | TotalAssetsBOY |
| Total Assets EOY | 34308543 | TotalAssetsEOY |
| Total Liabilities BOY | 5007660 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 5519538 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 24880988 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 28789005 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | OUR MISSION IS TO FOCUS ON THE NEEDS OF THOSE WE SERVE THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 2790369 | Expense |
| Revenue | 5136725 | Revenue |
| Description | THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,351 PATIENTS DAYS OF CARE IN 2012, DELIVERING 60 NEWBORNS FOR THE ELEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,364 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2012. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 2101457 | Expense |
| Revenue | 3757293 | Revenue |
| Description | THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 53 PATIENTS DAILY DURING 2012. SRMC PROVIDED 19,300 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1770596 | Expense |
| Revenue | 4224403 | Revenue |
| Description | SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. | Description |
Activity Other ActivityOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 26674794 | Expense |
| Revenue | 24677177 | Revenue |
| Description | OTHER MISCELLANOUES PATIENT SERVICES. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Other Program Service Exp | 26674794 | TotalOfOtherProgramServiceExp |
| Total Of Other Program Service Rev | 24677177 | TotalOfOtherProgramServiceRev |
| Total Program Service Expense | 33337216 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 43 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 413 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 13 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 11 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KELLY UTLEY | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 3082545825 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (20 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|---|
| BILL PILE | ||||||||
| CHAIRMAN | 1.00 | 0.00 | X | X | 0 | 0 | 0 | |
| TIM MILLER | ||||||||
| VICE CHAIRMAN | 1.00 | 0.00 | X | X | 0 | 0 | 0 | |
| TOM MILLMAN | ||||||||
| SECRETARY | 1.00 | 0.00 | X | X | 0 | 0 | 0 | |
| JEFF ELLWANGER | ||||||||
| TREASURER | 1.00 | 0.00 | X | X | 0 | 0 | 0 | |
| MICHAEL MATTHEWS MD | ||||||||
| MEMBER | 40.00 | 0.00 | X | 381554 | 0 | 12250 | ||
| STAN BELIEU | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| KATHY NARJES | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| JIM JONES | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| ROB ROBINSON | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| LAURIE WIDDOWSON | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| CALVIN CUTRIGHT MD | ||||||||
| MEMBER | 40.00 | 0.00 | X | 217552 | 0 | 22207 | ||
| DWIGHT SMITH | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| JULIE WAMSLEY | ||||||||
| MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | ||
| JASON PETIK | ||||||||
| CEO | 40.00 | 0.00 | X | 167062 | 0 | 19399 | ||
| KELLY UTLEY | ||||||||
| CFO | 39.00 | 1.00 | X | 121816 | 0 | 26510 | ||
| MANDY SHAW | ||||||||
| DOCTOR | 40.00 | 0.00 | 298869 | 0 | 12250 | X | ||
| JAMES THAYER | ||||||||
| SURGEON | 40.00 | 0.00 | 358060 | 0 | 34457 | X | ||
| DANA HLAVINKA | ||||||||
| CRNA | 40.00 | 0.00 | 192361 | 0 | 30771 | X | ||
| CLINTON DORWART | ||||||||
| DOCTOR | 40.00 | 0.00 | 228224 | 0 | 32579 | X | ||
| ROBERT GRAVES | ||||||||
| DOCTOR | 40.00 | 0.00 | 167366 | 0 | 23069 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 2132864 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 213492 | TotalOtherCompensation |
| Number Individuals GT100 K | 19 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 1 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| RURAL PARTNERS IN MEDICINE LLC | |||||
| PO BOX 772519 | STEAMBOAT SPRINGS | CO | 80477 | PHYSICIAN SERVICES | 1162192 |
| POUDRE VALLEY HEALTH CARE INC | |||||
| PO BOX 2103 | FORT COLLINS | CO | 80522 | MANAGEMENT SERVICES | 238831 |
| HEALTH CAROUSEL LLC | |||||
| PO BOX 44743 | MIDDLETOWN | OH | 45044 | HOME HEALTH CONTRACT SERVICES | 199426 |
| SEIM JOHNSON LLP | |||||
| 18081 BURT ST STE 200 | OMAHA | NE | 68022 | AUDIT & TAX SERVICES | 193542 |
| PANHANDLE TRANSCRIPTION | |||||
| PO BOX 407 | CHADRON | NE | 69337 | TRANSCRIPTION SERVICES | 148874 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 6 | NumberOfContractorsGT100K |
| Related Organizations | 26196 | RelatedOrganizations |
| All Other Contributions | 67312 | AllOtherContributions |
| Total Contributions | 93508 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (5 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| PATIENT SERVICE REVENUE NET OF CO | 624100 | 27815062 | 27815062 |
| MEDICARE/MEDICAID | 624100 | 9143155 | 9143155 |
| MISC. MEDICAL SERVICES | 621400 | 389430 | 389430 |
| HOME CARE | 621610 | 268955 | 268955 |
| MEDICAL SERVICES - COMMUNITY | 621400 | 104922 | 104922 |
Total Oth Program Service Revenue TotalOthProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 65856 | TotalRevenueColumn |
| Related Or Exempt Function Income | 65856 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 37787380 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 79977 | TotalRevenueColumn |
| Exclusion | $79,977 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 8358 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 8358 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 8358 | TotalRevenueColumn |
| Exclusion | $8,358 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 16765 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 20235 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -3470 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -3470 | TotalRevenueColumn |
| Exclusion | -$3,470 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | ExclusionExclusionAmount | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|---|
| CAFETERIA | 624100 | 104979 | $104,979 | |
| PATRONAGE DIVIDEND | 624100 | 35518 | $35,518 | |
| MEDICAL RECORDS | 624100 | 8218 | 8218 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 148715 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 38114468 | TotalRevenueColumn |
| Related Or Exempt Function Income | 37795598 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $225,362 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 148326 | Total |
| Management And General | 148326 | ManagementAndGeneral |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 633563 | Total |
| Program Services | 633563 | ProgramServices |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 14736591 | Total |
| Program Services | 14507506 | ProgramServices |
| Management And General | 229085 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 334898 | Total |
| Program Services | 333113 | ProgramServices |
| Management And General | 1785 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2351542 | Total |
| Program Services | 2317468 | ProgramServices |
| Management And General | 34074 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1081594 | Total |
| Program Services | 1056677 | ProgramServices |
| Management And General | 24917 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 186461 | Total |
| Management And General | 186461 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 69358 | Total |
| Management And General | 69358 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 110185 | Total |
| Management And General | 110185 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3923422 | Total |
| Program Services | 3793015 | ProgramServices |
| Management And General | 130407 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 93987 | Total |
| Program Services | 93987 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2481665 | Total |
| Program Services | 2478268 | ProgramServices |
| Management And General | 3397 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 971912 | Total |
| Program Services | 971912 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 174645 | Total |
| Program Services | 165906 | ProgramServices |
| Management And General | 8739 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 81081 | Total |
| Management And General | 81081 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1193047 | Total |
| Program Services | 1193047 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 446141 | Total |
| Program Services | 446141 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBTS | 2541612 | 2541612 | |
| MEDICAL SUPPLIES | 2447675 | 2447675 | |
| MISCELLANEOUS EXPENSE | 377578 | 232769 | 144809 |
| TAXES & LICENSES | 128227 | 100740 | 27487 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 45170 | Total |
| Program Services | 23817 | ProgramServices |
| Management And General | 21353 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 34558680 | Total |
| Program Services | 33337216 | ProgramServices |
| Management And General | 1221464 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12976872 | BOY |
| EOY | 4547176 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1178213 | BOY |
| EOY | 9240879 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4554336 | BOY |
| EOY | 6549084 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 636117 | BOY |
| EOY | 895473 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 225212 | BOY |
| EOY | 205422 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 25127247 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 13495810 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10015823 | BOY |
| EOY | 11631437 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 248228 | BOY |
| EOY | 81017 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 53847 | BOY |
| EOY | 1158055 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29888648 | BOY |
| EOY | 34308543 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2479010 | BOY |
| EOY | 3105212 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2229673 | BOY |
| EOY | 1926291 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 266585 | BOY |
| EOY | 233054 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32392 | BOY |
| EOY | 254981 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5007660 | BOY |
| EOY | 5519538 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24878090 | BOY |
| EOY | 28789005 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2898 | BOY |
| EOY | 0 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24880988 | BOY |
| EOY | 28789005 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29888648 | BOY |
| EOY | 34308543 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 3555788 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 352229 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $4,873 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 4873 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1: | ReturnReference |
| Explanation | A PORTION OF THE DUES PAID TO AHA AND NHA ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 92500 | InvestmentCostOrOtherBasis |
| Other Cost Or Other Basis | 526741 | OtherCostOrOtherBasis |
| Book Value | 619241 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 15125016 | OtherCostOrOtherBasis |
| Depreciation | 7586141 | Depreciation |
| Book Value | 7538875 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 8614039 | OtherCostOrOtherBasis |
| Depreciation | 5579927 | Depreciation |
| Book Value | 3034112 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 768951 | OtherCostOrOtherBasis |
| Depreciation | 329742 | Depreciation |
| Book Value | 439209 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 11631437 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| DUE TO CHEYENNE COUNTY HOSP & HEALTH CARE FOUNDATION | $15 |
| DEFERRED COMPENSATION PLAN LIABILITY | $254,966 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 254981 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | Identifier |
| Return Reference | PART X, LINE 2: | ReturnReference |
| Explanation | SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2009. | Explanation |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 251348 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 251348 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00790 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2916635 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2917219 | DirectOffsettingRevenue |
| Net Community Benefit Expense | -584 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3167983 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2917219 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 250764 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00790 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 179060 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 50902 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 128158 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00400 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 45426 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 45426 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00140 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 9430 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 9430 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00030 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 233916 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 50902 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 183014 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00570 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3401899 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2968121 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 433778 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01360 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $2,541,612 | BadDebtExpenseAmount |
| Amount Attributable To | 1078036 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 9910491 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 10047291 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -136800 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION DBA | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 100.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 300.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Uninsured Discount | X | UninsuredDiscount |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 2 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (2 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| SIDNEY REG'L MEDICAL CTR EXTENDED CARE | ||||
| 645 OSAGE | SIDNEY | NE | 69162 | LONG TERM CARE FACILITY |
| SLOAN ESTATES ASSISTED LIVING | ||||
| 2550 CRAIG AVENUE | SIDNEY | NE | 69162 | ASSISTED LIVING |
Form990 Schedule H Part VI Form990ScheduleHPartVI (16 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 3C: NOT APPLICABLE. | ||
| PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER. | ||
| PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. | ||
| PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES. | ||
| PART I, L7 COL(F): BAD DEBT EXPENSE OF $2,541,612 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. | ||
| PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE", AND "CHARITY CARE":PATIENT RECEIVABLES, NET:THE SYSTEM REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS, AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM 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 SYSTEM 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 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.NET PATIENT SERVICE REVENUE:THE SYSTEM HAS AGREEMENTS WITH THIRD-PARTY PAYERS THAT PROVIDE FOR PAYMENTS TO THE SYSTEM 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.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 SYSTEM DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE COMBINED STATEMENTS OF OPERATIONS. | ||
| PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2012 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. MEDICARE SHORTFALLS IN PAYMENT SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. | ||
| PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE. TO ENHANCE OUR STANDARD CHARITY PROGRAM, SIDNEY REGIONAL MEDICAL CENTER (SRMC) CURRENTLY UTILIZES A PRESUMPTIVE CHARITY SCREENING PRIOR TO REFERRING ACCOUNTS TO BAD DEBT WITH AN OBJECTIVE TO WRITE OFF ACCOUNTS OF THE MOST ELIGIBLE AND IN-NEED FAMILIES OR INDIVIDUALS. | ||
| PART V, SECTION B, LINE 14G: OUR FINANCIAL ASSISTANCE POLICY IS WELL VERSED AMONGST THE PATIENT FINANCIAL SERVICES REPRESENTATIVES. THE FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH WOULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. AS WELL, THE FINANCIAL ASSISTANCE PROGRAM IS COMMUNICATED WITH PATIENTS WHO INDICATE THAT THEY ARE HAVING TROUBLE. | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | |
| PART V, SECTION B, LINE 20D: THIS IS ADJUSTED AS A PERCENT OF CHARGES BASED ON THE FEDERAL POVERTY GUIDELINES. | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | |
| PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS, UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. | ||
| PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNINSURED OR UNDERINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE &/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEET WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY, THE NEEDS OF THE INDIVIDUALS WITH RESPECT TO ABILITIES, AND THE AMOUNT OF ASSISTANCE NEEDED. | ||
| PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2014. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 43.7. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2014. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. | ||
| PART VI, LINE 5: SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2012 AS THE PRESIDENT OF THE FINANCE COMMITTEE FOR PANHANDLE PUBLIC HEALTH AND A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST BASED REIMBURSED AND, IN FACT, ERODE THE COST BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF THE DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. | ||
| PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. | ||
| NE | REPORTS FILED WITH STATES | PART VI, LINE 7 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 1 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (8 entries)
| TitleTitle | Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MICHAEL MATTHEWS MD | ||||||||||||||
| MEMBER | 380974 | 0 | 0 | 0 | 580 | 0 | 12250 | 0 | 0 | 0 | 393804 | 0 | 0 | 0 |
| CALVIN CUTRIGHT MD | ||||||||||||||
| MEMBER | 214971 | 0 | 0 | 0 | 2581 | 0 | 0 | 0 | 22207 | 0 | 239759 | 0 | 0 | 0 |
| JASON PETIK | ||||||||||||||
| CEO | 167062 | 0 | 0 | 0 | 0 | 0 | 1915 | 0 | 17484 | 0 | 186461 | 0 | 0 | 0 |
| MANDY SHAW | ||||||||||||||
| DOCTOR | 298755 | 0 | 0 | 0 | 114 | 0 | 12250 | 0 | 0 | 0 | 311119 | 0 | 0 | 0 |
| JAMES THAYER | ||||||||||||||
| SURGEON | 356976 | 0 | 0 | 0 | 1084 | 0 | 12250 | 0 | 22207 | 0 | 392517 | 0 | 0 | 0 |
| DANA HLAVINKA | ||||||||||||||
| CRNA | 192222 | 0 | 0 | 0 | 139 | 0 | 10120 | 0 | 20651 | 0 | 223132 | 0 | 0 | 0 |
| CLINTON DORWART | ||||||||||||||
| DOCTOR | 226806 | 0 | 0 | 0 | 1418 | 0 | 9510 | 0 | 23069 | 0 | 260803 | 0 | 0 | 0 |
| ROBERT GRAVES | ||||||||||||||
| DOCTOR | 166789 | 0 | 0 | 0 | 577 | 0 | 0 | 0 | 23069 | 0 | 190435 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| PART I, LINE 5 | DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALLY, HE RECEIVES A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. | |
| PART III | JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY HEALTH CARE, INC., AN UNRELATED ENTITY. POUDRE VALLEY HEALTH CARE, INC. PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED $167,062 SALARY, $1,915 RETIREMENT BENEFITS, AND $17,484 NONTAXABLE BENEFITS. | SUPPLEMENTAL INFORMATION |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | POUDRE VALLEY HEALTH CARE, INC. CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. SRMC PROVIDES POUDRE VALLEY HEALTH CARE WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY MONTHLY FOR COMPARISON DATA PURPOSES. | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE ORGANIZATION'S ACCOUNTING DEPARTMENT PREPARES AN ORGANIZER SUPPLIED BY THE ACCOUNTING FIRM SEIM JOHNSON, LLP AND SUBMITS THE ORGANIZER TO THE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. | |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. | |
| FORM 990, PART VI, SECTION B, LINE 15 | POUDRE VALLEY HEALTH CARE, INC. PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC USES A METHOD ANNUALLY TO DETERMINE EXECUTIVE SALARY RANGES WHEREBY SRMC PULLS RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGES FOR EACH EXECUTIVE POSITION ACCORDING TO THEIR GEOGRAPHICAL REGION. THESE ARE THEN REVIEWED AND THEN PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. | |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT OUT ONCE A YEAR TO COMMUNITY LEADERS. | |
| FORM 990, PART VII, SECTION A, LINE 1A: | JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY HEALTH CARE INC., WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. | OFFICERS PAID BY UNRELATED ORGANIZATION |
| FORM 990, PART VII, SECTION A | MICHAEL MATTHEWS, MD AND CALVIN CUTRIGHT, MD ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE NOT BEING PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS. | |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 2,676,255. MANAGEMENT AND GENERAL EXPENSES 130,407. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,806,662. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 1,116,760. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,116,760. | OTHER FEES |
| FORM 990, PART XI, LINE 9: | HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES' NET ASSETS 352,229. | CHANGES IN NET ASSETS OR FUND BALANCES: |
| FORM 990, PART XI, LINE 2C: | THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. | COMMITTEE WITH OVERSIGHT OF THE AUDIT |
| FORM 990, PART XI, LINE 9: | AS OF DECEMBER 31, 2011 THE COMBINED FINANCIAL STATEMENTS INCLUDE THE ACCOUNTS OF CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL MEDICAL CENTER, CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION, AND HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES. DURING 2011, THE HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES' (SMA) BOARD OF DIRECTORS APPROVED THE DISSOLUTION OF SMA EFFECTIVE JANUARY 1, 2012. UPON DISSOLUTION, SMA DISTRIBUTED ITS ASSETS AFTER PAYING ALL EXISTING LIABILITIES, TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL MEDICAL CENTER. SIDNEY REGIONAL MEDICAL CENTER ASSUMED OPERATIONS AND RECEIVED APPROVAL FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICES FOR THE CLINIC TO BE DESIGNATED AS A PROVIDER-BASED RURAL HEALTH CLINIC (RHC) EFFECTIVE JANUARY 1, 2012. | OTHER CHANGES IN NET ASSETS: |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Direct Controlling Entity NADirectControllingEntityNA | Controlled OrgControlledOrg |
|---|---|---|---|---|---|---|---|---|---|---|
| CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | ||||||||||
| 645 OSAGE | SIDNEY | NE | 69162 | 470686476 | SUPPORT SIDNEY REGIONAL MEDICAL CENTER | NE | 501(C)(3) | LINE 11C, III-FI | N/A | 0 |
| WESTERN NEBRASKA HEALTH SYSTEMS | ||||||||||
| 645 OSAGE | SIDNEY | NE | 69162 | 911774837 | SUPPORT SIDNEY REGIONAL MEDICAL CENTER | NE | 501(C)(3) | LINE 9 | N/A | 0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |