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HIAWATHA HOSPITAL ASSOCIATION INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
HIAWATHA HOSPITAL ASSOCIATION INC (EIN 48-0577658)
Tax period
2012-01-01 to 2012-12-31
Filed
2013-11-15
IRS object ID
201333199349304118
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 ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-11-15T10:22:40-06:00Timestamp
Tax Period End Date2012-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1BKD LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line11201 Walnut Suite 1700AddressLine1
CityKansas CityCity
StateMOState
ZIP Code641062246ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN480577658EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1Hiawatha Hospital Association IncBusinessNameLine1
FieldValueIRS element (for citing)
In Care Of Name% JENNY KNUDSONInCareOfName
Name ControlHIAWNameControl
Phone7857422131Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1300 UTAH STREETAddressLine1
Address Line2SuiteAddressLine2
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameJOHN MOOREName
TitleCEOTitle
Phone7857422131Phone
Date Signed2013-11-15DateSigned
Authorize Third PartytrueAuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameKevin Ensminger CPAName
Phone8162216300Phone
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonJOHN MOORENameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1300 UTAH STREETAddressLine1
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode
FieldValueIRS element (for citing)
Gross Receipts22921922GrossReceipts
Group Return For AffiliatesfalseGroupReturnForAffiliates
Organization501c3XOrganization501c3
Web Sitewww.hch-ks.orgWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1945YearFormation
State Legal DomicileKSStateLegalDomicile
Activity Or Mission DescriptionAS A RURAL COMMUNITY HOSPITAL, HIAWATHA HOSPITAL ASSOCIATION'S PRIMARY GOAL IS TO PROVIDE MODERN, RELIABLE, AND AFFORDABLE HEALTH SERVICES THAT BEST MEET THE NEEDS OF OUR COMMUNITY RESIDENTS.ActivityOrMissionDescription
Nbr Voting Members Governing Body10NbrVotingMembersGoverningBody
Nbr Independent Voting Members9NbrIndependentVotingMembers
Total Nbr Employees274TotalNbrEmployees
Total Nbr Volunteers8TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year40041ContributionsGrantsPriorYear
Contributions Grants Current Year58393ContributionsGrantsCurrentYear
Program Service Revenue Prior Year20741703ProgramServiceRevenuePriorYear
Program Service Revenue CY22690658ProgramServiceRevenueCY
Investment Income Prior Year33122InvestmentIncomePriorYear
Investment Income Current Year31804InvestmentIncomeCurrentYear
Other Revenue Prior Year90569OtherRevenuePriorYear
Other Revenue Current Year113873OtherRevenueCurrentYear
Total Revenue Prior Year20905435TotalRevenuePriorYear
Total Revenue Current Year22894728TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year17531GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY21726GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year11727896SalariesEtcPriorYear
Salaries Etc Current Year13103213SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year5324TotalFundrsngExpCurrentYear
Other Expense Prior Year9679192OtherExpensePriorYear
Other Expenses Current Year10343832OtherExpensesCurrentYear
Total Expenses Prior Year21424619TotalExpensesPriorYear
Total Expenses Current Year23468771TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-519184RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-574043RevenuesLessExpensesCY
Total Assets BOY24378272TotalAssetsBOY
Total Assets EOY25398373TotalAssetsEOY
Total Liabilities BOY9657668TotalLiabilitiesBOY
Total Liabilities EOY11230380TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY14720604NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY14167993NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionSEE SCHEDULE OMissionDescription
Significant New Program ServicesfalseSignificantNewProgramServices
Significant ChangefalseSignificantChange
Expense19871019Expense
Grants21726Grants
Revenue22690658Revenue
DescriptionSEE SCHEDULE ODescription
Total Program Service Expense19871019TotalProgramServiceExpense
Described In501 C3trueDescribedIn501C3
Schedule B RequiredtrueScheduleBRequired
Political ActivitiesfalsePoliticalActivities
Lobbying ActivitiestrueLobbyingActivities
Subject To Proxy TaxfalseSubjectToProxyTax
Donor Advised FundsfalseDonorAdvisedFunds
Conservation EasementsfalseConservationEasements
Collections Of ArtfalseCollectionsOfArt
Credit CounselingfalseCreditCounseling
Term Or Permanent EndowmentsfalseTermOrPermanentEndowments
Report Land Bldg EquiptrueReportLandBldgEquip
Report Invest Oth SecuritiesfalseReportInvestOthSecurities
Report Prog Rel InvestfalseReportProgRelInvest
Report Other AssetsfalseReportOtherAssets
Report Other LiabilitiesfalseReportOtherLiabilities
Report Fin48 FootnotetrueReportFin48Footnote
Independent Audit Financial StmtfalseIndependentAuditFinancialStmt
Consolidated Audit Financial StmttrueConsolidatedAuditFinancialStmt
SchoolfalseSchool
Foreign OfficefalseForeignOffice
Foreign ActivitiesfalseForeignActivities
More Than5000 K To OrganizationsfalseMoreThan5000KToOrganizations
More Than5000 K To IndividualsfalseMoreThan5000KToIndividuals
Professional FundraisingfalseProfessionalFundraising
Fundraising ActivitiesfalseFundraisingActivities
GamingfalseGaming
HospitaltrueHospital
Financial Stmt AttachedtrueFinancialStmtAttached
Grants To OrganizationstrueGrantsToOrganizations
Grants To IndividualstrueGrantsToIndividuals
Schedule J RequiredtrueScheduleJRequired
Tax Exempt BondstrueTaxExemptBonds
Invest Tax Exempt BondsfalseInvestTaxExemptBonds
Escrow AccountfalseEscrowAccount
On Behalf Of IssuerfalseOnBehalfOfIssuer
Excess Benefit TransactionfalseExcessBenefitTransaction
Prior Excess Benefit TransactionfalsePriorExcessBenefitTransaction
Loan To Officer Or DQPfalseLoanToOfficerOrDQP
Grant To Related PersonfalseGrantToRelatedPerson
Bsnss Rltnshp With OrganizationfalseBsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family MemberfalseBsnssRltnshpThruFamilyMember
Officer Entity With Bsnss RltnshpfalseOfficerEntityWithBsnssRltnshp
Deductible Non Cash ContributionsfalseDeductibleNonCashContributions
Deductible Contributions Of ArtfalseDeductibleContributionsOfArt
TerminatedfalseTerminated
Partial LiquidationfalsePartialLiquidation
Disregarded EntityfalseDisregardedEntity
Related EntitytrueRelatedEntity
Related Org Controlled EntitytrueRelatedOrgControlledEntity
Transaction Related EntitytrueTransactionRelatedEntity
Transfers To Exempt Non Chrtbl OrgfalseTransfersToExemptNonChrtblOrg
Activities Conducted PartnershipfalseActivitiesConductedPartnership
Schedule O RequiredtrueScheduleORequired
Number Forms Transmitted With109630NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup WitholdingtrueComplianceWithBackupWitholding
Number Of Employees274NumberOfEmployees
Employment Tax Returns FiledtrueEmploymentTaxReturnsFiled
Unrelated Business IncomefalseUnrelatedBusinessIncome
Foreign Financial AccountfalseForeignFinancialAccount
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTrans
Taxable Party NotificationfalseTaxablePartyNotification
Non Deductible ContributionsfalseNonDeductibleContributions
Quid Pro Quo ContributionsfalseQuidProQuoContributions
Form8282 Property Disposed OffalseForm8282PropertyDisposedOf
Funds To Pay PremiumsfalseFundsToPayPremiums
Premiums PaidfalsePremiumsPaid
Indoor Tanning ServicesfalseIndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members10NbrVotingGoverningBodyMembers
Number Independent Voting Members9NumberIndependentVotingMembers
Family Or Business RelationshiptrueFamilyOrBusinessRelationship
Delegation Of Management DutiesfalseDelegationOfManagementDuties
Changes To Organizing DocsfalseChangesToOrganizingDocs
Material Diversion Or MisusefalseMaterialDiversionOrMisuse
Members Or StockholdersfalseMembersOrStockholders
Election Of Board MembersfalseElectionOfBoardMembers
Decisions Subject To ApprovalfalseDecisionsSubjectToApproval
Minutes Of Governing BodytrueMinutesOfGoverningBody
Minutes Of CommitteestrueMinutesOfCommittees
Officer Mailing AddressfalseOfficerMailingAddress
Local ChaptersfalseLocalChapters
Form990 Provided To Governing BodytrueForm990ProvidedToGoverningBody
Conflict Of Interest PolicytrueConflictOfInterestPolicy
Annual Disclosure Covered PersonstrueAnnualDisclosureCoveredPersons
Regular Monitoring EnforcementtrueRegularMonitoringEnforcement
Whistleblower PolicytrueWhistleblowerPolicy
Document Retention PolicytrueDocumentRetentionPolicy
Compensation Process CEOtrueCompensationProcessCEO
Compensation Process OtherfalseCompensationProcessOther
Investment In Joint VenturefalseInvestmentInJointVenture
States Where Copy Of Return Is FiledKSStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

FieldValueIRS element (for citing)
Name PersonJENNY KNUDSONNamePerson
Telephone Number7857426210TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1300 UTAH STREETAddressLine1
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (16 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekAverage Hours Per Week RelatedAverageHoursPerWeekRelatedIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficerHighest Compensated EmployeeHighestCompensatedEmployee
ANDY PETERSON
TRUSTEE1.00.0X000
LORI ELLIOT
TRUSTEE1.00.0X000
FONDA LAFRENZ
TRUSTEE1.00.0X492000
ERIC MCPEAK
TRUSTEE/VICE PRESIDENT1.00.0X000X
HILLARY BOYE
TRUSTEE1.00.0X000
CHERYL RASMUSSEN
TRUSTEE1.00.0X000
GALEN MEYER
TRUSTEE1.00.0X000
DEL ELFFNER
TRUSTEE/VICE PRESIDENT1.00.0X000X
RANDY FEE
TRUSTEE/SECRETARY/TREASURER1.00.0X000X
DR PETE ROSA
MD/TRUSTEE40.00.0X245118031380
JOHN MOORE
ADMINISTRATOR/CEO40.00.0147804021570X
DR BRYON BIGHAM
MD40.00.0223144032256X
DR STEFFEN SHAMBURG
MD40.00.0407896038037X
DR JULIE ROSA
MD40.00.0124875022301X
DR CROSBY GERNON
MD40.00.0459746053331X
JEAN ABEITA
PHARMACIST40.00.011365000X
FieldValueIRS element (for citing)
Total Reportable Comp From Org1727153TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation198875TotalOtherCompensation
Number Individuals GT100 K9NumberIndividualsGT100K
Formers ListedfalseFormersListed
Total Comp GT150 KtrueTotalCompGT150K
Compensation From Other SourcesfalseCompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Description Of ServicesDescriptionOfServicesCompensationCompensation
STEVEN H GUNNELS ANESTHESIA
ANESTHESIA652680
STARS INC
THERAPY559855
ORANGE COMMERCIAL
CONTRACT NURSING201180
SHARED MEDICAL SERVICES
MRI184600
ST FRANCIS HOSPITAL MEDICAL
MEDICAL TESTING178642
FieldValueIRS element (for citing)
Number Of Contractors GT100 K8NumberOfContractorsGT100K
Government Grants24714GovernmentGrants
All Other Contributions33679AllOtherContributions
Total Contributions58393TotalContributions

Program Service Revenue ProgramServiceRevenue (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
PATIENT SERVICE REVENUE6211102132370921323709
OTHER PATIENT REVENUE6211101453014530
340B Pharmacy44611013524191352419
FieldValueIRS element (for citing)
Total Program Service Revenue22690658TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column31804TotalRevenueColumn
Exclusion$31,804ExclusionAmount

Income From Invest Bond Proceeds IncomeFromInvestBondProceeds

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Royalties Revenue RoyaltiesRevenue

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real62225Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real27194Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real35031Real
Personal0Personal

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column35031TotalRevenueColumn
Exclusion$35,031ExclusionAmount

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Net Income From Fundraising Events NetIncomeFromFundraisingEvents

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Net Income From Gaming NetIncomeFromGaming

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Net Income Or Loss NetIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Other Revenue Misc OtherRevenueMisc

FieldValueIRS element (for citing)
DescriptionCAFETERIA INCOMEDescription
Business Code722210BusinessCode
Total Revenue Column78842TotalRevenueColumn
Exclusion$78,842ExclusionAmount
FieldValueIRS element (for citing)
Total Other Revenue78842TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column22894728TotalRevenueColumn
Related Or Exempt Function Income22690658RelatedOrExemptFunctionIncome
Exclusion$145,677ExclusionAmount
FieldValueIRS element (for citing)
Info In Schedule O Part IXXInfoInScheduleOPartIX

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total9152Total
Program Services9152ProgramServices

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total12574Total
Program Services12574ProgramServices

Foreign Grants ForeignGrants

FieldValueIRS element (for citing)
Total0Total

Benefits To Members BenefitsToMembers

FieldValueIRS element (for citing)
Total0Total

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total442670Total
Program Services390826ProgramServices
Management And General51844ManagementAndGeneral

Comp Disqual Persons CompDisqualPersons

FieldValueIRS element (for citing)
Total0Total

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total9568618Total
Program Services8305413ProgramServices
Management And General1263205ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total351153Total
Program Services296600ProgramServices
Management And General54553ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total2060713Total
Program Services1605458ProgramServices
Management And General455255ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total680059Total
Program Services598433ProgramServices
Management And General81626ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total0Total

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total13306Total
Management And General13306ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total154455Total
Management And General154455ManagementAndGeneral

Fees For Services Lobbying FeesForServicesLobbying

FieldValueIRS element (for citing)
Total0Total

Fees For Services Prof Fundraising FeesForServicesProfFundraising

FieldValueIRS element (for citing)
Total0Total

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total0Total

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total2879949Total
Program Services2493732ProgramServices
Management And General380893ManagementAndGeneral
Fundraising5324Fundraising

Advertising Advertising

FieldValueIRS element (for citing)
Total67511Total
Program Services38831ProgramServices
Management And General28680ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total755621Total
Program Services646989ProgramServices
Management And General108632ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total71432Total
Program Services28836ProgramServices
Management And General42596ManagementAndGeneral

Royalties Royalties

FieldValueIRS element (for citing)
Total0Total

Occupancy Occupancy

FieldValueIRS element (for citing)
Total358341Total
Program Services257329ProgramServices
Management And General101012ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total47376Total
Program Services36163ProgramServices
Management And General11213ManagementAndGeneral

Travel Entrtnmnt Public Officials TravelEntrtnmntPublicOfficials

FieldValueIRS element (for citing)
Total0Total

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total53579Total
Program Services27423ProgramServices
Management And General26156ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total310192Total
Program Services244899ProgramServices
Management And General65293ManagementAndGeneral

Payments To Affiliates PaymentsToAffiliates

FieldValueIRS element (for citing)
Total0Total

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total1333728Total
Program Services884906ProgramServices
Management And General448822ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total177765Total
Program Services95978ProgramServices
Management And General81787ManagementAndGeneral

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
BAD DEBT EXPENSE654087654087
REPAIRS & MAINTENANCE37733529785379482
DUES & SUBSCRIPTIONS1129716072152250
Medical Supplies2428785242870481

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total547399Total
Program Services456112ProgramServices
Management And General91287ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total23468771Total
Program Services19871019ProgramServices
Management And General3592428ManagementAndGeneral
Fundraising5324Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY286BOY
EOY286EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY5293805BOY
EOY5154075EOY

Pledges And Grants Receivable PledgesAndGrantsReceivable

FieldValueIRS element (for citing)
BOY50121BOY
EOY50121EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY3238196BOY
EOY2924348EOY

Receivables From Officers Etc ReceivablesFromOfficersEtc

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Receivables From Disqual Persons ReceivablesFromDisqualPersons

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY673802BOY
EOY506334EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY263635BOY
EOY196833EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis29231006LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec13685802LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY14651059BOY
EOY15545204EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Investments Program Related InvestmentsProgramRelated

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Intangible Assets IntangibleAssets

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY207368BOY
EOY1021172EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY24378272BOY
EOY25398373EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY2138236BOY
EOY2232855EOY

Grants Payable GrantsPayable

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Deferred Revenue DeferredRevenue

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Tax Exempt Bond Liabilities TaxExemptBondLiabilities

FieldValueIRS element (for citing)
BOY4520000BOY
EOY4335000EOY

Escrow Account Liability EscrowAccountLiability

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Loans From Officers Directors LoansFromOfficersDirectors

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY2999432BOY
EOY4662525EOY

Unsecured Notes Loans Payable UnsecuredNotesLoansPayable

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY9657668BOY
EOY11230380EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY14654349BOY
EOY14102888EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY66255BOY
EOY65105EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY14720604BOY
EOY14167993EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY24378272BOY
EOY25398373EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses-574043ReconcilationRevenueExpenses
Reconcilation Other Changes21432ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or ReviewfalseAccountantCompileOrReview
FS AuditedtrueFSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement ConsolidatedXFinancialStatementConsolidated
FieldValueIRS element (for citing)
Audit CommitteetrueAuditCommittee
Federal Grant Audit RequiredfalseFederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

Total Grassroots Lobbying TotalGrassrootsLobbying

FieldValueIRS element (for citing)
Filing Organizations Totals4425FilingOrganizationsTotals
FieldValueIRS element (for citing)
Total Direct LobbyingTotalDirectLobbying

Total Lobbying Expenditures TotalLobbyingExpenditures

FieldValueIRS element (for citing)
Filing Organizations Totals4425FilingOrganizationsTotals

Other Exempt Purpose Expenditures OtherExemptPurposeExpenditures

FieldValueIRS element (for citing)
Filing Organizations Totals19866594FilingOrganizationsTotals

Total Exempt Purpose Expenditures TotalExemptPurposeExpenditures

FieldValueIRS element (for citing)
Filing Organizations Totals19871019FilingOrganizationsTotals

Lobbying Nontaxable LobbyingNontaxableAmount

FieldValueIRS element (for citing)
Filing Organizations Totals1000000FilingOrganizationsTotals

Grassroots Nontaxable GrassrootsNontaxableAmount

FieldValueIRS element (for citing)
Filing Organizations Totals250000FilingOrganizationsTotals
FieldValueIRS element (for citing)
Tot Lobbying Grassroot Minus Non TxTotLobbyingGrassrootMinusNonTx
Tot Lobby Expend Mns Lobbying NontxTotLobbyExpendMnsLobbyingNontx
Form4720 FiledfalseForm4720Filed

Lobbying Nontaxable Amount2 LobbyingNontaxableAmount2

FieldValueIRS element (for citing)
Current Year Minus3971194CurrentYearMinus3
Current Year Minus2967803CurrentYearMinus2
Current Year Minus11000000CurrentYearMinus1
Current Year1000000CurrentYear
Total3938997Total
FieldValueIRS element (for citing)
Lobbying Ceiling$5,908,496LobbyingCeilingAmount

Total Lobbying Expenditures2 TotalLobbyingExpenditures2

FieldValueIRS element (for citing)
Current Year Minus33916CurrentYearMinus3
Current Year Minus24082CurrentYearMinus2
Current Year Minus14401CurrentYearMinus1
Current Year4425CurrentYear
Total16824Total

Grassroots Nontaxable Amount2 GrassrootsNontaxableAmount2

FieldValueIRS element (for citing)
Current Year Minus3242799CurrentYearMinus3
Current Year Minus2241951CurrentYearMinus2
Current Year Minus1250000CurrentYearMinus1
Current Year250000CurrentYear
Total984750Total
FieldValueIRS element (for citing)
Grassroots Ceiling$1,477,125GrassrootsCeilingAmount

Grassroots Lobbying Expenditures GrassrootsLobbyingExpenditures

FieldValueIRS element (for citing)
Current Year Minus33916CurrentYearMinus3
Current Year Minus24082CurrentYearMinus2
Current Year Minus14401CurrentYearMinus1
Current Year4425CurrentYear
Total16824Total

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Art Public Exhibition AmtsArtPublicExhibitionAmts
Held Works Of Art AmtsHeldWorksOfArtAmts
Current Year Minus3 YearsCurrentYearMinus3Years
Current Year Minus4 YearsCurrentYearMinus4Years

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis769309OtherCostOrOtherBasis
Book Value769309BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis17172578OtherCostOrOtherBasis
Depreciation6686608Depreciation
Book Value10485970BookValue
FieldValueIRS element (for citing)
Leasehold ImprovementsLeaseholdImprovements

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis8224627OtherCostOrOtherBasis
Depreciation6544345Depreciation
Book Value1680282BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis3064492OtherCostOrOtherBasis
Depreciation454849Depreciation
Book Value2609643BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings15545204TotalOfBookValueLandBuildings
Federal Income Tax Liability0FederalIncomeTaxLiability
Total Of Amounts0TotalOfAmounts

Form990 Schedule D Part XIII Form990ScheduleDPartXIII

FieldValueIRS element (for citing)
IdentifierUNCERTAIN TAX POSITIONS DISCLOSUREIdentifier
Return ReferenceSCHEDULE D, PART X, LINE 2ReturnReference
ExplanationMANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.Explanation

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care PolicytrueCharityCarePolicy
Written PolicytrueWrittenPolicy
FPG Reference Free CaretrueFPGReferenceFreeCare
Pcent150XPcent150
FPG Reference Discounted CaretrueFPGReferenceDiscountedCare
Pcent200 DXPcent200D
Free Disc Care Medically IndigenttrueFreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity CarefalseAmountsBudgetedForCharityCare
Annual Community Benefit ReportfalseAnnualCommunityBenefitReport

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense479016TotalCommunityBenefitExpense
Net Community Benefit Expense479016NetCommunityBenefitExpense
Percent Of Total Expense0.02040PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense2783058TotalCommunityBenefitExpense
Direct Offsetting Revenue1316801DirectOffsettingRevenue
Net Community Benefit Expense1466257NetCommunityBenefitExpense
Percent Of Total Expense0.06250PercentOfTotalExpense

Unreimbursed Costs UnreimbursedCosts

FieldValueIRS element (for citing)
Total Community Benefit Expense251298TotalCommunityBenefitExpense
Direct Offsetting Revenue186190DirectOffsettingRevenue
Net Community Benefit Expense65108NetCommunityBenefitExpense
Percent Of Total Expense0.00280PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense3513372TotalCommunityBenefitExpense
Direct Offsetting Revenue1502991DirectOffsettingRevenue
Net Community Benefit Expense2010381NetCommunityBenefitExpense
Percent Of Total Expense0.08570PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense24640TotalCommunityBenefitExpense
Direct Offsetting Revenue10974DirectOffsettingRevenue
Net Community Benefit Expense13666NetCommunityBenefitExpense
Percent Of Total Expense0.00060PercentOfTotalExpense

Health Professions Education HealthProfessionsEducation

FieldValueIRS element (for citing)
Total Community Benefit Expense937TotalCommunityBenefitExpense
Net Community Benefit Expense937NetCommunityBenefitExpense
Percent Of Total Expense0.00010PercentOfTotalExpense

Cash And In Kind Contributions CashAndInKindContributions

FieldValueIRS element (for citing)
Total Community Benefit Expense10000TotalCommunityBenefitExpense
Direct Offsetting Revenue0DirectOffsettingRevenue
Net Community Benefit Expense10000NetCommunityBenefitExpense
Percent Of Total Expense0.00040PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense35577TotalCommunityBenefitExpense
Direct Offsetting Revenue10974DirectOffsettingRevenue
Net Community Benefit Expense24603NetCommunityBenefitExpense
Percent Of Total Expense0.00110PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense3548949TotalCommunityBenefitExpense
Direct Offsetting Revenue1513965DirectOffsettingRevenue
Net Community Benefit Expense2034984NetCommunityBenefitExpense
Percent Of Total Expense0.08680PercentOfTotalExpense

Economic Development EconomicDevelopment

FieldValueIRS element (for citing)
Total Community Building Expense2867TotalCommunityBuildingExpense
Net Community Building Expense2867NetCommunityBuildingExpense
Percent Of Total Expense0.00010PercentOfTotalExpense

Health Improvement Advocacy HealthImprovementAdvocacy

FieldValueIRS element (for citing)
Total Community Building Expense24640TotalCommunityBuildingExpense
Direct Offsetting Revenue10974DirectOffsettingRevenue
Net Community Building Expense13666NetCommunityBuildingExpense
Percent Of Total Expense0.00060PercentOfTotalExpense

Total Total

FieldValueIRS element (for citing)
Total Community Building Expense27507TotalCommunityBuildingExpense
Direct Offsetting Revenue10974DirectOffsettingRevenue
Net Community Building Expense16533NetCommunityBuildingExpense
Percent Of Total Expense0.00070PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense ReportedfalseBadDebtExpenseReported
Bad Debt Expense$654,087BadDebtExpenseAmount
Amount Attributable To13082AmountAttributableTo
Amount Reimbursed By Medicare7235584AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare7869379CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall-633795MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost To Charge RatioXCostToChargeRatio
FieldValueIRS element (for citing)
Written Debt Collection PolicytrueWrittenDebtCollectionPolicy
Provision For Charity CaretrueProvisionForCharityCare
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1HIAWATHA HOSPITAL ASSOCIATIONBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line1300 UTAH STREETAddressLine1
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Critical Access HospitalXCriticalAccessHospital
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1HIAWATHA HOSPITAL ASSOCIATIONBusinessNameLine1
FieldValueIRS element (for citing)
Eligibility Criteria ExplainedtrueEligibilityCriteriaExplained
Uses FPG FreetrueUsesFPGFree
FPG Free Percent150.FPGFreePercent
Uses FPG DiscountedtrueUsesFPGDiscounted
FPG Discount Percent200.FPGDiscountPercent
Explains BasistrueExplainsBasis
Income LevelXIncomeLevel
Asset LevelXAssetLevel
Medical IndigencyXMedicalIndigency
Uninsured DiscountXUninsuredDiscount
Medicaid MedicareXMedicaidMedicare
Explains Application MethodtrueExplainsApplicationMethod
Includes Publicity MeasurestrueIncludesPublicityMeasures
Posted On WebsiteXPostedOnWebsite
Attached To InvoicesXAttachedToInvoices
Provided On AdmissionXProvidedOnAdmission
Available On RequestXAvailableOnRequest
Actions On NonpaymenttrueActionsOnNonpayment
Collection ActivitiesfalseCollectionActivities
Notify Upon AdmissionXNotifyUponAdmission
Notify Before DischargeXNotifyBeforeDischarge
Notified All PatientsXNotifiedAllPatients
Nondiscrim Emergency Care PolicytrueNondiscrimEmergencyCarePolicy
Used Other MethodXUsedOtherMethod
Amounts Generally BilledfalseAmountsGenerallyBilled
Gross ChargesfalseGrossCharges

Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC

FieldValueIRS element (for citing)
Number Of Other Facilities3NumberOfOtherFacilities

Other Facilities OtherFacilities (3 entries)

Address Line1Address/AddressLine1CityAddress/CityStateAddress/StateZIP CodeAddress/ZIPCodeFacility TypeFacilityType
HIAWATHA COMMUNITY HOSPITAL HOME HEALTH
300 UTAH STREETHIAWATHAKS66434HOME HEALTH AGENCY
HIAWATHA COMM HOSP FAM PRACTICE CLINIC
300 OREGON STREET 2ND FLOORHIAWATHAKS66434RURAL HEALTH CLINIC
HIAWATHA COMM HOSPITAL HIGHLAND CLINIC
415 S MAIN STREETHIAWATHAKS66434RURAL HEALTH CLINIC

Form990 Schedule H Part VI Form990ScheduleHPartVI (10 entries)

IdentifierIdentifierExplanationExplanationReturn ReferenceReturnReference
SCHEDULE H, PART I, LINE 7, COLUMN FTHE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES FOR CALCULATING THE NET COMMUNITY BENEFIT EXPENSE PERCENTAGE WAS $654,087.
SCHEDULE H, PART I, LINE 7THE HOSPITAL USES THE COST-TO-CHARGE RATIO. THIS METHOD WAS USED TO CALCULATE THE FIGURES IN THE TABLE AND WAS DETERMINED BY COMPARING PATIENT CARE COST TO PATIENT CARE CHARGES.
COMMUNITY BUILDING ACTIVITIESECONOMIC DEVELOPMENT - HHA EMPLOYEE REPRESENTS THE HOSPITAL ON THE HIAWATHA ECONOMIC DEVELOPMENT COUNCIL TO DISCUSS THE HOSPITAL'S INVOLVEMENT IN IMPROVING THE COMMUNITY'S ECONOMIC HEALTH AND DEVELOPMENT. COMMUNITY HEALTH IMPROVEMENT ADVOCACY - OPERATION OF COMMUNITY DAY CARE AND A WEIGHT LOSS CLINIC TO BETTER SUPPORT THE HOSPITAL'S COMMUNITY & HEALTHY LIVING.SCHEDULE H, PART II, LINES 2 & 7
BAD DEBT EXPENSEThe Hospital reports patient accounts receivable for services rendered at net realizable amounts from third-party payers, patients and others. The Hospital provides an allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information, and existing economic conditions. As a service to the patient, the Hospital bills third-party payers directly and bills the patient when the patient's liability is determined. Patient accounts receivable 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. Line 2 is THE ORGANIZATION'S BAD DEBT FIGURE NET OF COLLECTIONS AND THEN MULTIPLIED BY THE ORGANIZATION'S COST TO CHARGE RATIO. THE ORGANIZATION FIGURED 2% OF THOSE BELONG IN CHARITY CARE BUT WERE INELIGIBLE BECAUSE THEY WOULDN'T COMPLETE PAPERWORK OR THE BUSINESS OFFICE DIDN'T HAVE ENOUGH INFORMATION TO BE ABLE TO SEND THEM TO PRESUMPTIVE CHARITY CARE.SCHEDULE H, PART III, LINE 4
COLLECTION PRACTICESON EACH STATEMENT WE STATE THAT WE HAVE A CHARITY CARE POLICY. FOR 3 MONTHS A STATEMENT IS SENT. AFTER 3RD STATEMENT, A COLLECTION LETTER GOES OUT WITH A CHARITY CARE APPLICATION. THE FOLLOWING MONTH IT IS LISTED ON THE BAD DEBT LIST. AT THE END OF THE FOLLOWING MONTH THE ACCOUNT IS WRITTEN OFF TO BAD DEBT AND SENT TO COLLECTIONS, OR LITIGATION. IF IT GOES TO LITIGATION, NOTIFICATION IS MADE THROUGH CERTIFIED MAIL. ANOTHER CHARITY CARE APPLICATION IS SENT ALONG WITH THE NOTIFICATION LETTER.SCHEDULE H, PART III, LINE 9B
UNINSURED PATIENT BILLINGUninsured patients are offered a 10% discount on charges.SCHEDULE H, PART V, LINE 19D
NEEDS ASSESSMENTTHE ASSESSMENT OF COMMUNITY NEEDS IS A COMPILATION OF ISSUES IDENTIFIED BY THE ADMINISTRATOR, PHYSICIANS, NURSING STAFF, GOVERNING BOARD, AND INFORMAL COMMUNITY INPUT. THESE ISSUES ARE VALIDATED AND SUPPLEMENTED BY CONTRACTOR STUDIES AND GOVERNMENTAL AGENCY FEEDBACK.SCHEDULE H, PART VI, LINE 2
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCETHE HOSPITAL'S SOCIAL SERVICES DEPARTMENT SPEAKS WITH PATIENTS REGARDING ELIGIBILITY FOR CHARITY CARE, MEDICAID, AND VARIOUS OTHER ASSISTANCE PROGRAMS THAT ARE AVAILABLE. OUR BUSINESS OFFICE MANAGER ALSO SPEAKS WITH PATIENTS REGARDING THE AVAILABILITY FOR DISABILITY DETERMINATION. PROVIDERS OFTEN BRING UP OUR CHARITY CARE PROGRAM WITH PATIENTS AT TIME OF TREATMENT. A CHARITY CARE PAMPHLET IS AVAILABLE AT ADMISSIONS AND APPLICATIONS ARE OFTEN HANDED OUT AT TIME OF ADMISSION FOR OUTPATIENT SERVICES. THE CHARITY CARE POLICY IS ALSO PUBLISHED ON OUR WEBSITE. THE FACT THAT WE HAVE A CHARITY CARE PROGRAM IS PRINTED ON THE BOTTOM OF EVERY STATEMENT THAT GOES OUT. THE CHARITY CARE APPLICATION IS PRINTED ON THE BACK OF ALL COLLECTION LETTERS AND PRE-LITIGATION CERTIFIED LETTERS.SCHEDULE H, PART VI, LINE 3
COMMUNITY INFORMATIONOUR GEOGRAPHIC AREA INCLUDES ALL OF BROWN COUNTY AND PARTS OF DONIPHAN, ATCHISON, AND NEMAHA COUNTIES IN KANSAS AND PARTS OF RICHARDSON COUNTY NEBRASKA. 55% OF OUR COMMUNITY IS 45 YEARS OLD AND UNDER. 26% IS AGE 45 TO 64. 19% OF THE POPULATION IS OVER 65 YEARS OF AGE. 26% OF THE COMMUNITY HOUSEHOLDS ARE BELOW THE POVERTY LEVEL FOR A FAMILY OF FOUR.SCHEDULE H, PART VI, LINE 4
PROMOTION OF COMMUNITY HEALTHAS A TAX EXEMPT, NOT FOR PROFIT ENTITY, HIAWATHA COMMUNITY HOSPITAL'S PURPOSE IS TO PROVIDE THE BEST SERVICES POSSIBLE IN A MANNER THAT IS ACCESSIBLE TO ALL INDIVIDUALS. OFFERING OUR SERVICES AT NO, OR REDUCED COST TO THOSE WHO MEET OUR CHARITY REQUIREMENTS IS A CONERSTONE OF OUR MISSION. AS THE ECONOMIC CLIMATE IN THE COMMUNITY CHANGED, SO DID OUR CHARITY CARE SERVICES. IN 2010 WE BEGAN A PRESUMPTIVE CHARITY CARE PROGRAM THAT ALLOWS US TO GRANT CHARITY CARE TO THOSE INDIVIDUALS WHO QUALIFY BUT WON'T COMPLETE THE REQUIRED PAPERWORK WE NEED TO SUBSTANTIATE THE NEED FOR ASSISTANCE. ALSO SUPPPORTING OUR STATUS IS OUR COMMITMENT TO PROVIDE QUALITY SERVICE AND STAFF. TO THAT END, THE HIAWATHA COMMUNITY HOSPITAL PROVIDES SCHOLARSHIPS FOR EDUCATION IN HEALTH RELATED FIELDS. ANOTHER MANNER IN WHICH WE SUPPORT OUR NOT FOR PROFIT STATUS IS THROUGH PUBLIC HEALTH EDUCATIONAL PROGRAMS FOR THE COMMUNITY. WE PROVIDE DIABETES, HYPERTENSION AND SMOKING CESSATION EDUCATION. WE ALSO RUN A WEIGHT LOSS CLINIC.SCHEDULE H, PART VI, LINE 5

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records MaintainedtrueRecordsMaintained

Recipient Table RecipientTable

Recipient Name Business RecipientNameBusiness

FieldValueIRS element (for citing)
Business Name Line1LITTLE HANDS DAYCARE OF HIAWATHABusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1200 EAST LODGE ROADAddressLine1
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode
FieldValueIRS element (for citing)
EIN Of Recipient264051457EINOfRecipient
IRC Section501(C)(3)IRCSection
Amount Of Cash Grant10000AmountOfCashGrant
Method Of ValuationCASHMethodOfValuation
Purpose Of GrantOPERATIONAL SUPPORTPurposeOfGrant

Form990 Schedule I Part III Form990ScheduleIPartIII

FieldValueIRS element (for citing)
Type Of GrantSCHOLARSHIPSTypeOfGrant
Number Of Recipients8NumberOfRecipients
Amount Of Cash Grant12574AmountOfCashGrant

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierPROCESS FOR MONITORING SCHOLARSHIPSIdentifier
Return ReferenceSCHEDULE I, PART IIIReturnReference
Explanation1) COMMUNITY SCHOLARSHIP - HCH HAS GIVEN SCHOLARSHIPS TO COMMUNITY MEMBERS PURSUING A DEGREE IN THE MEDICAL FIELD. AFTER THE SCHOLARSHIP IS APPROVED BY HOSPITAL CEO, THE TUITION IS PAID TO THE SCHOOL, THE STUDENT OR THE STUDENT LOAN HOLDER.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance PaymentfalseSeverancePayment
Supplemental Nonqual Retire PlanfalseSupplementalNonqualRetirePlan
Equity Based Comp ArrangementfalseEquityBasedCompArrangement
Comp Based On Revenue Of Filing OrgfalseCompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related OrgsfalseCompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing OrgtrueCompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate OrgsfalseCompBasedNetEarningsRelateOrgs
Any Non Fixed PaymentsfalseAnyNonFixedPayments
Initial Contract ExceptionfalseInitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)

TitleTitleBase Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgs
DR BRYON BIGHAM
MD198336024808000855102370502554000
JOHN MOORE
ADMINISTRATOR/CEO14780400000002157001693740
DR STEFFEN SHAMBURG
MD27746301304330001144202659504459330
DR PETE ROSA
MD/TRUSTEE189476055642000811302326702764980
DR CROSBY GERNON
MD3996240601220001881003452105130770

Form990 Schedule J Part III Form990ScheduleJPartIII

FieldValueIRS element (for citing)
IdentifierCOMPENSATION CONTIGENT ON NET EARNINGSIdentifier
Return ReferenceSCHEDULE J, PART I, LINE 6AReturnReference
ExplanationThe family physicians that are contracted with the hospital to provide services in our rural health care clinic and our radiologist are all eligible for additional compensation beyond their base pay rate. Each physician's expenses and revenues are tracked through their own department. Periodically throughout the year, if their respective departments are showing a positive net income, then they are eligible to receive additional compensation. The amount of net revenue to be distributed mid year is decided between the physicians and the Administrator. By the year end, 100% of the net revenue will be distributed as long as it doesn't exceed the annual maximum compensation amounts in the physician's respective contracts. To determine what each physician's portion of the distribution will be, income statements are run by physician that include allocations for building expenses and expenses and revenues from mid-levels.Explanation

Schedule K IRS990ScheduleK

Form990 Schedule K Part I Form990ScheduleKPartI

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd

Issuer Name IssuerName

FieldValueIRS element (for citing)
Business Name Line1CITY OF HIAWATHABusinessNameLine1
FieldValueIRS element (for citing)
Issuer EIN483025665IssuerEIN
CUSIP Number428545BD8CUSIPNumber
Date Issued2007-03-29DateIssued
Issue Price5175000IssuePrice
Description Of PurposeSEE SCHEDULE K, PART VDescriptionOfPurpose
DefeasedfalseDefeased
On Behalf Of IssuerfalseOnBehalfOfIssuer
Pool FinancingfalsePoolFinancing

Form990 Schedule K Part II Form990ScheduleKPartII

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Amount Retired840000AmountRetired
Amount Bond Defeased0AmountBondDefeased
Total Proceeds5175000TotalProceeds
Amount In Reserve Fund0AmountInReserveFund
Capitalized Interest0CapitalizedInterest
Refunding Escrow0RefundingEscrow
Issuance Costs From Proceeds105804IssuanceCostsFromProceeds
Credit Enhancement0CreditEnhancement
Working Capital Expenditures0WorkingCapitalExpenditures
Capital Expenditures5069196CapitalExpenditures
Other Spent Proceeds0OtherSpentProceeds
Amount Unspent0AmountUnspent
Year Of Subst Completion2007YearOfSubstCompletion
Current RefundingtrueCurrentRefunding
Advance RefundingfalseAdvanceRefunding
Final Allocation MadetrueFinalAllocationMade
Adequate Books And Recds MaintaindtrueAdequateBooksAndRecdsMaintaind

Form990 Schedule K Part III Form990ScheduleKPartIII

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Owning Bond Financed PropertyfalseOwningBondFinancedProperty
Any Lease ArrangementsfalseAnyLeaseArrangements
Mngment Cntrct Bond Financd PrprtyfalseMngmentCntrctBondFinancdPrprty
Any Research AgreementstrueAnyResearchAgreements
Engage Bond Counsel ResearchtrueEngageBondCounselResearch
Prcntge Prvt Business Use By Others0.00000PrcntgePrvtBusinessUseByOthers
Percentage Of Prvt Business Re UBI0.00000PercentageOfPrvtBusinessReUBI
Total Private Business Use0.00000TotalPrivateBusinessUse
Bond Iss Meet Prvt Security Pay TesttrueBondIssMeetPrvtSecurityPayTest
Change In Use Bond Financed PropfalseChangeInUseBondFinancedProp
Remedial Action TakenfalseRemedialActionTaken
Non Qualified Bond Remed ProcdrstrueNonQualifiedBondRemedProcdrs

Form990 Schedule K Part IV Form990ScheduleKPartIV

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Form8038 T FiledfalseForm8038TFiled
Rebate Not Due YetfalseRebateNotDueYet
Exception To RebatefalseExceptionToRebate
No Rebate DuefalseNoRebateDue
Variable Rate IssuefalseVariableRateIssue
Hedge Identified In Books And RecdsfalseHedgeIdentifiedInBooksAndRecds

Name Of Hedge Provider NameOfHedgeProvider

FieldValueIRS element (for citing)
Business Name Line10BusinessNameLine1
FieldValueIRS element (for citing)
Gross Proceeds Invested In GICfalseGrossProceedsInvestedInGIC

Name Of GIC Provider NameOfGICProvider

FieldValueIRS element (for citing)
Business Name Line10BusinessNameLine1
FieldValueIRS element (for citing)
Gross Proceeds InvestedfalseGrossProceedsInvested
Written Proc To Monitor ReqsfalseWrittenProcToMonitorReqs

Form990 Schedule K Part V Form990ScheduleKPartV

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Proc To Undertk Corrective ActionfalseProcToUndertkCorrectiveAction

Form990 Schedule K Part VI Form990ScheduleKPartVI

FieldValueIRS element (for citing)
IdentifierDESCRIPTION OF PURPOSEIdentifier
Return Reference0ReturnReference
ExplanationREFINANCE EXISTING BOND TO BUILDExplanation

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (10 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
ORGANIZATION'S MISSIONFORM 990, PART III, LINE 1HIAWATHA COMMUNITY HOSPITAL'S HIGHEST PRIORITY IS THE PROVISION OF QUALITY HEALTH CARE TO OUR PATIENTS THROUGHOUT NORTHEAST KANSAS. COMPREHENSIVE SERVICES INCLUDE PRIMARY, SECONDARY, AND LONG-TERM CARE. TO CARRY OUT THIS MISSION, HEALTH PROFESSIONALS WITHIN THE HOSPITAL CONTINUALLY WORK TOGETHER TO IMPROVE PATIENT CARE AND EDUCATION. THIS TEAM APPROACH ASSURES THAT OUR PATIENTS WILL BENEFIT FROM THE MOST UP-TO-DATE MEDICAL PRACTICES AVAILABLE. THE HOSPITAL CAN ONLY CONTINUE TO EXIST TO SERVE ITS MISSION THROUGH SOUND FINANCIAL MANAGEMENT AND STRATEGIC PLANNING. THEREFORE, THE PRINCIPLES OF COST EFFECTIVENESS AND EFFICIENCY GOVERN THE DEVELOPMENT OF HEALTH CARE POLICY FOR THE HOSPITAL. EXTERNAL AND INTERNAL ASSESSMENTS ARE DONE TO DETERMINE EVOLUTIONARY NEEDS AND TO RESPOND TO THE DEMANDS OF EVER-CHANGING TECHNOLOGY. HIAWATHA COMMUNITY HOSPITAL FEELS A STRONG COMMITMENT TO ITS EMPLOYEES AND STRIVES ALWAYS TO TREAT THEM FAIRLY, RESPONSIBLY, AND WITH A SENSE OF CONCERN FOR THEIR WELL-BEING. THE PROVISION OF COMPREHENSIVE CONTINUING EDUCATION IS ESSENTIAL TO MAINTAIN ADEQUATE SKILL LEVELS AND FOSTER A SENSE OF PRIDE AND PROFESSIONALISM. AS A COMMUNITY HOSPITAL, HIAWATHA COMMUNITY HOSPITAL RECOGNIZES ITS RESPONSIBILITY TO PROVIDE PUBLIC HEALTH EDUCATION AND, AS SUCH, STRIVES TO SERVE AS A REGIONAL HEALTH RESOURCE CENTER. MEDICAL AND PROFESSIONAL STAFF ARE ENCOURAGED TO PARTICIPATE IN COMMUNITY ACTIVITIES AND EDUCATION.
PROGRAM SERVICE ACCOMPLISHMENTFORM 990, PART III, LINE 4AAS A TAX-EXEMPT, NOT-FOR-PROFIT ENTITY, HIAWATHA COMMUNITY HOSPITAL'S PURPOSE IS TO PROVIDE THE BEST SERVICES POSSIBLE IN A MANNER THAT IS ACCESSIBLE TO ALL INDIVIDUALS. OFFERING OUR SERVICES AT NO OR REDUCED COST TO THOSE WHO MEET OUR CHARITY REQUIREMENTS IS A CORNERSTONE OF OUR MISSION. TO ENSURE THAT AS MANY INDIVIDUALS AS POSSIBLE ARE DEEMED ELIGIBLE FOR CHARITY CARE, WE IMPLEMENTED A PRESUMPTIVE CHARITY CARE PROGRAM. THIS PROGRAM WILL VERIFY PATIENT FINANCIAL SITUATIONS ALLOWING US TO INCLUDE THEM IN THE CHARITY CARE PROGRAM EVEN IF THEY DON'T WANT TO COMPLETE THE PAPERWORK THEMSELVES. WE FEEL THAT THIS PROGRAM IS A GREAT WAY TO GET INDIVIUALS IN NEED THE CARE THEY DESERVE WITHOUT ADDED FINANCIAL STRESS. ALSO SUPPORTING OUR TAX-EXEMPT STATUS IS OUR COMMITMENT TO PROVIDE QUALITY SERVICE AND STAFF. TO THAT END, THE HIAWATHA COMMUNITY HOSPITAL DISTRIBUTED OVER $12,000 IN SCHOLARSHIPS IN 2012. ANOTHER MANNER IN WHICH WE SUPPORT OUR NOT-FOR-PROFIT STATUS IS THROUGH PUBLIC HEALTH EDUCATIONAL PROGRAMS FOR THE COMMUNITY. WE PROVIDE DIABETES, HYPERTENSION, AND SMOKING CESSATION EDUCATION. FINALLY, IN ADDRESSING COMMUNITY CONCERN FOR SAFE PLACES FOR CHILDREN, WE DONATED $10,000 TO THE NEW NOT-FOR-PROFIT COMMUNITY DAY CARE FACILITY IN TOWN.
FORM 990 REVIEW PROCESSFORM 990, PART VI, SECTION B, LINE 11BAN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT NEED TO BE MADE ARE MADE. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING THE 990.
CONFLICT OF INTEREST POLICYFORM 990, PART VI, SECTION B, LINE 12CAll employees and decision makers for the Hospital are covered under this policy. Conflicts are either reviewed by the Corporate Compliance Officer or the Board President. At Board meetings, the Board Chair is appraised of all conflicts of interest and then asks the member to abstain from discussing and voting on topics of conflict.
COMPENSATION REVIEWFORM 990, PART VI, SECTION B, LINE 15ATHE DIRECTOR OF HUMAN RESOURCES PERIODICALLY PROVIDES THE PRESIDENT OF THE BOARD OF DIRECTORS WITH A COMPENSATION SURVEY COMPILED BY THE KANSAS HOSPITAL ASSOCIATION. THE SURVEY DELINEATES COMPENSATION PACKAGES FOR ADMINISTRATORS AT HOSPITALS THAT ARE SIMILAR TO HIAWATHA. BASED ON THAT SURVEY, THE ADMINISTRATOR'S PERFORMANCE, AND THE PERFORMANCE OF THE HOSPITAL, THE BOARD SETS THE ADMINISTRATOR'S SALARY.
AVAILABILITY OF DOCUMENTSFORM 990, PART VI, LINE 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
RECONCILIATION OF NET ASSETSFORM 990, PART XI, LINE 5CHANGE IN FOUNDATION ASSETS $ 22,582 NET ASSETS RELEASED FROM RESTRICTION $ ( 1,150) ---------- TOTAL $ 21,432
OTHER FEES FOR SERVICES FOR NON-EMPLOYEESFORM 990 PART IX LINE 11GDESCRIPTION:CONTRACTED MEDICAL SERVICES TOTAL FEES:2493732
OTHER FEES FOR SERVICES FOR NON-EMPLOYEESFORM 990 PART IX LINE 11GDESCRIPTION:CONTRACTED BILLING/ADMIN SRVCS TOTAL FEES:380893
OTHER FEES FOR SERVICES FOR NON-EMPLOYEESFORM 990 PART IX LINE 11GDESCRIPTION:PERSONNEL & ADMIN FNDRSING SRV TOTAL FEES:5324

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1HIAWATHA HOSPITAL ASSOCIATION FOUNDATIONBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1300 UTAH STREETAddressLine1
CityHIAWATHACity
StateKSState
ZIP Code66434ZIPCode
FieldValueIRS element (for citing)
EIN481223766EIN
Primary ActivitiesFUNDRAISINGPrimaryActivities
Legal Domicile StateKSLegalDomicileState
Exempt Code Section503(C)(3)ExemptCodeSection
Public Charity Status11APublicCharityStatus

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1HHABusinessNameLine1
FieldValueIRS element (for citing)
Controlled OrgtrueControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents RoyaltiesfalseReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other OrgfalseGiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other OrgfalseGiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other OrgfalseLoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other OrgfalseSaleOfAssetsToOtherOrg
Purchase Of Assets From Other OrgfalsePurchaseOfAssetsFromOtherOrg
Exchange Of AssetsfalseExchangeOfAssets
Rental Of Facilities To Other OrgsfalseRentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other OrgsfalseRentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other OrgsfalsePerformOfServicesForOtherOrgs
Perform Of Services By Other OrgsfalsePerformOfServicesByOtherOrgs
Sharing Of FacilitiestrueSharingOfFacilities
Sharing Of Paid EmployeestrueSharingOfPaidEmployees
Reimbursement Paid To Other OrgfalseReimbursementPaidToOtherOrg
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrg
Other Transfer To Other OrgfalseOtherTransferToOtherOrg
Other Transfer From Other OrgtrueOtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable

Name Of Other Organization NameOfOtherOrganization

FieldValueIRS element (for citing)
Business Name Line1HIAWATHA HOSPITAL ASSOCIATION FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Transaction TypeSTransactionType
Amount Involved78606AmountInvolved
Method Of Amt DeterminationFMVMethodOfAmtDetermination