2013-04-29T11:32:22-05:00 2012-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2011-07-01 440629397 Carroll County Memorial Hospital CARR 6605421695 1502 N Jefferson St Carrollton MO 64633 Jeff Tindle 6605421695 2013-04-26 1 Eric L Otting P00298454 7852334226 2013-04-26 2011 2016-03-07 17:11:31Z Jeff Tindle 1502 N Jefferson St Carrollton MO 64633 12866040 0 X carrollcountyhospital.org X 1957 MO Carroll County Memorial Hospital is committed to meeting the changing needs of our community by providing comprehensive innovative and professional quality Healthcare Services. 9 9 181 22 0 0 1740 2265 12289337 11417157 198503 203028 164159 1243590 12653739 12866040 2500 5000 0 0 7063626 6370781 0 0 0 6015750 6111294 13081876 12487075 -428137 378965 23189013 24796834 1624253 2874488 21564760 21922346 To improve the health of the community by assuring excellent medical care to our citizens. 0 0 9210443 11417157 Acute care hospital organized to provide inpatient and outpatient care to area residents regardless of their ability to pay. 9210443 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10 0 1 181 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 0 0 MO X X X Jeff Tindle CEO 6605421695 1502 North Jefferson Carrollton MO 64633 Ben Polen 4.00 X 0 0 0 Jim Gibson 4.00 X 0 0 0 Charlie Lock 4.00 X 0 0 0 Blake Riley 4.00 X 0 0 0 Linda Ross 4.00 X 0 0 0 Debbie Minnick 4.00 X 0 0 0 Rex Buhrmester 4.00 X 0 0 0 Carolyn Lock 4.00 X 0 0 0 Randall Barry 4.00 X 0 0 0 Jerry Dover 40.00 X 205108 0 14891 Jeffrey Tindle 40.00 X 116426 0 18295 Waclaw ADymek 40.00 X 203962 0 0 Julie Marvin 40.00 X 119240 0 9675 Richard Smith 40.00 X 309658 0 15147 Tim Reid 40.00 X 166190 0 15682 1120584 0 73690 6 0 1 0 Cerner Corporation PO Box 412702 Kansas City MO 64141 Computer Systems 307978 HSMC Technology Services Inc 3550 NE Ralph Powell Rd Lees Summit MO 64064 IT Service 204691 Richard L Smith MD 20644 HWY Z Chillicothe MO 64601 ER Physician Coverage 176289 Clinishare Inc 19600 E 39th Street Independence MO 64057 Nuclear Medicine 170867 HMN Architects Inc 7400 W 110th St Overland Park KS 66210 Architectural Services 164675 8 2265 2265 Net Patient service re 621990 11417157 11417157 11417157 151997 151997 58202 0 58202 58202 58202 51031 0 51031 51031 51031 EHR incentive payments 900009 1108760 1108760 Other income 900099 57345 57345 Medical record fees 621990 8832 8832 10451 10451 1185388 12866040 11417157 0 1446618 X 5000 5000 428795 428795 4770233 4067372 702861 271201 233529 37672 515234 411807 103427 385318 303382 81936 6241 227 6014 655888 554773 101115 27944 8749 19195 129393 2890 126503 90074 1269 88805 438899 146474 292425 72233 63213 9020 1223895 1223895 147079 147079 Contract labor 842674 606058 236616 Collection fees and bad 439721 439721 Pharmaceuticals 377604 377604 Medical supplies 374527 374527 1285122 389953 895169 12487075 9210443 3276632 0 8223551 7058597 1186139 1662591 119724 123491 90850 69670 22259219 10232552 10448077 12026667 1969846 1773144 1150826 2082674 23189013 24796834 1157222 1093625 1430682 467031 350181 1624253 2874488 X 21564760 21922346 21564760 21922346 23189013 24796834 X 378965 -21379 X X 0 1 1 X 0 X 22259219 10232552 12026667 12026667 Equity securities 459836 F Corporate bonds 1313308 F 1773144 Interest receivable 1895 Estimated third-party payor settlements 1888000 Other receivables 192779 2082674 Property and equipment purchases payable 146465 Purchase agreement 203716 350181 12866040 12487075 378965 -21379 -21379 357586 12844661 -21379 -21379 12866040 0 12866040 12487075 0 12487075 0 12487075 1 1 1 X 1 X 1 1 1 0 1 1 136684 81072 55612 0.00460 1833985 1378211 455774 0.03780 1970669 1459283 511386 0.04240 3211 3211 0.00030 6500 6500 0.00050 3314367 2583209 731158 0.06070 3090 3090 0.00030 3327168 2583209 743959 0.06180 5297837 4042492 1255345 0.10420 1 275242 222010 5483550 5688384 -204834 X 1 1 1 1 Carroll County Memorial Hospital

1502 North Jefferson Carrollton MO 64633

X X X X Physician clinics Carroll County Memorial Hospital 1 1 0 0 0 1 1 1 100.000000000000 1 200.000000000000 1 X X X 0 1 X X 1 X X 0 1 X 0 0 4 Jefferson Medical Group - Carrollton

1403 N Jefferson Carrollton MO 64633

Rural health clinic Jefferson Medical Group - Norborne

105 East 2nd St Norborne MO 64668

Rural health clinic Jefferson Medical Group - Hale

321 Elm St Hale MO 64643

Rural health clinic Reid Medical Group

1401 N Jefferson Carrollton MO 64633

Rural health clinic 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 $ 433454. Part III, Line 4: The Hospital provides for accounts receivable that could become uncollectible in the future by establishing an allowance to reduce the carrying value of such receivables to their estimated net realizable value. The Hospital estimates this allowance based on the aging of each type of payor.The Hospital's bad debt at cost was determined by applying an overall ratio of cost to charges. The amount of bad debt attributable to patients eligible for charity care is based on self-pay only patients and patients covered by Medicaid. Part III, Line 8: Amounts were obtained from the cost report filed with Medicare for the period ending June 30, 2012. Part III, Line 9b: Each patient is provided with payment information in clear, easy-to-understand language. CCMH checks on public-assistance programs to see if the patient qualifies. The Hospital offers discounts on charges to underinsured and uninsured patients when possible. Carroll County Memorial Hospital Part V, Section B, Line 17e: Financial counseling with self-pay patients. Carroll County Memorial Hospital Part V, Section B, Line 19d: The Hospital utilizes a standardized charge rate for each procedure and supply charged to patients regardless of payor type or ability to pay. Part VI, Line 2: Carroll County Memorial Hospital relies on interaction with local health care agencies as well as feedback from patients and primary service area residents to assess the health care needs of the community. Part VI, Line 3: Carroll County Memorial Hospital provides each patient with a letter that clearly states payment information in an easy-to-understand language. The Hospital informs patients promptly about the charge for any item or service provided. The letter informs the patient that if they are not able to pay their hospital bill that there are programs that may help alleviate the burden. If the Hospital is prompted it will check for public-assistance or charity care programs to see if the patient qualifies. Part VI, Line 4: Carroll County Memorial Hospital is located in Carrollton, Missouri. The Hospitals primary service area consists of Carrollton and the surrounding areas in Carroll County. Carroll County Memorial Hospital operates two satellite clinics located in Hale and Norborne. Carroll County has a population of approximately 9,300 residents, with 35% of the residents living in urban areas and 65 % living rural in rural areas. The median annual household income for Carroll County is approximately $36,500. Approximately 13.7% of Carroll County residents have annual income below the federal poverty level, and 4.5% of Carroll County residents have annual income below 50% of the federal poverty level. The closest hospitals are located in Marshall, Lexington, and Richmond. The distance between Carroll County Memorial Hospital and these facilities is approximately 20, 25, and 27 miles. Part VI, Line 5: The Hospital's Board of Directors is elected from the local community and surrounding area that comprises the local service area. The Hospital's active medical staff members are residents of the county. CCMH sponsors community health fairs and education classes in many areas. Any surplus in funds are reinvested in the Hospital's facilities and patient service programs. CCMH has invested over $15 million in patient care improvements over the past 8 years. 0 0 0 0 0 0 0 0 0 Jerry Dover 205108 0 0 0 0 0 10996 0 3895 0 219999 0 0 0 Waclaw ADymek 87286 0 0 0 116676 0 0 0 0 0 203962 0 0 0 Richard Smith 160923 0 0 0 148735 0 11252 0 3895 0 324805 0 0 0 Tim Reid 143550 0 0 0 22640 0 11787 0 3895 0 181872 0 0 0 Andrew Horine Medical School X 100000 100000 0 1 1 100000 Form 990, Part VI, Section B, line 11 A copy of the Form 990 is provided to members of the Board of Directors prior to filing. Form 990, Part VI, Section B, line 12c The Board sets policy and administration is charged with assuring that compliance is maintained. In 2011 a Director of Compliance was hired and oversees all compliance matters. Form 990, Part VI, Section B, line 15a The CEO is hired, reviewed and compensation is set by the Board. All other management positions are hired, reviewed and monitored by the CEO, CNO and CFO. Form 990, Part VI, Section C, line 19 As a private not for profit we do not fall under the same rules of open meeting, however we do post our meetings in the local newspaper and would honor a request for review/discussion of our financials. All Other Functional Expenses Form 990, Part X, line 24e Medicaid FRA Tax: Program service expenses 0. Management and general expenses 369,743. Fundraising expenses 0. Total expenses 369,743. Repairs and maintenance: Program service expenses 113,228. Management and general expenses 118,643. Fundraising expenses 0. Total expenses 231,871. Minor equipment: Program service expenses 2,137. Management and general expenses 203,366. Fundraising expenses 0. Total expenses 205,503. Equipment rental and maintenance: Program service expenses 133,404. Management and general expenses 4,544. Fundraising expenses 0. Total expenses 137,948. Dietary supplies: Program service expenses 0. Management and general expenses 83,013. Fundraising expenses 0. Total expenses 83,013. Miscellaneous: Program service expenses 25,732. Management and general expenses 45,515. Fundraising expenses 0. Total expenses 71,247. Telecommunications: Program service expenses 16,702. Management and general expenses 40,492. Fundraising expenses 0. Total expenses 57,194. Health information management: Program service expenses 51,775. Management and general expenses 0. Fundraising expenses 0. Total expenses 51,775. License and dues: Program service expenses 29,600. Management and general expenses 21,107. Fundraising expenses 0. Total expenses 50,707. Electronic billing: Program service expenses 17,375. Management and general expenses 1,016. Fundraising expenses 0. Total expenses 18,391. Vending: Program service expenses 0. Management and general expenses 7,365. Fundraising expenses 0. Total expenses 7,365. Employee and physician recruitment: Program service expenses 0. Management and general expenses 365. Fundraising expenses 0. Total expenses 365. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -21,379. Financial Statements FORM 990, PART XII, LINE 2c The Carrol County Memorial Hospital Board along with Administration assumes responsibility.