2013-11-12T08:08:53-06:00 2012-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2012-01-01 480684878 Southwest Medical Center SOUT 6206241651 PO Box 1340 Liberal KS 679011340 Lori Smith 6206241651 2013-11-11 1 John R Helms P00203953 7852334226 2013-11-11 2012 2016-02-24 21:20:13Z Lori Smith PO Box 1340 Liberal KS 679011340 41840169 0 X www.swmedcenter.com X 1963 KS The Medical Center is a county hospital dedicated to the provision of personalized and quality care of the sick and injured at a reasonable cost. 7 7 463 144 0 0 285714 280310 43645696 40651431 -43103 109653 672901 798775 44561208 41840169 0 0 0 0 21005656 21512010 0 0 0 22834424 19179337 43840080 40691347 721128 1148822 55655149 56210435 21799136 21205600 33856013 35004835 The Medical Center is a county hospital dedicated to the provision of personalized and quality care of the sick and injured at a reasonable cost. 0 0 34996655 41256746 Southwest Medical Center provides necessary medical care to the community. It is the only facility in the area providing certain medical equipment and services. 34996655 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 43 0 1 463 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 1 1 0 X Lori Smith 6206296680 PO Box 1340 Liberal KS 679011340 Joe Sealey 1.00 X X 0 0 0 Ray E Allen MD 1.00 X X 0 0 0 Gary Andrews 1.00 X X 0 0 0 Jay Hay 1.00 X X 0 0 0 Mark Schepers 1.00 X X 0 0 0 Kim Yount DDS 1.00 X 0 0 0 Thomas Willis 1.00 X 0 0 0 William Ermann 40.00 X 151344 0 21623 Michelle M Gillespie 40.00 X 145160 0 16155 Jo Harrison 40.00 X 128227 0 20643 Robert Trivett 40.00 X 72389 0 10735 William R Valdez MD 40.00 X 488377 0 29403 Lawrence P Shank 40.00 X 481973 0 29330 Eve C Shank 40.00 X 345693 0 19927 Rory Howard 40.00 X 333412 0 26178 Francisco Chacon 40.00 X 177494 0 15347 Norman Lambert 40.00 X 251389 0 9826 2575458 0 199167 13 1 1 0 Comphealth PO Box 972651 Dallas TX 75397 Locum tenens 1227975 Nabholz Construction Services 1120 East Reno Avnue Oklahoma City OK 73117 Construction contractor 706243 Account Recovery Specialist Inc 200 W Wyatt Earp Blvd Dodge City KS 67801 Collection services 590422 Medical Information Technology Meditech Circle Westwood MA 02090 IT services 530600 Kansas Emergency Room Services PA 7032 Collection Center Drive Chicago IL 60693 ER services 467661 16 236034 9935 34341 61034 280310 Net patient service revenue 621990 40651431 40651431 40651431 109653 109653 Electronic health records incenti 900099 431443 431443 Cafeteria & dietary 722210 193460 193460 Home medical equipment 900099 123760 123760 50112 50112 798775 41840169 41256746 0 303113 585743 585743 16314045 14589623 1724422 1195346 1070867 124479 1737086 1531538 205548 1679790 1456166 223624 151672 151672 2100 2100 464092 143373 320719 326424 120241 206183 1178915 1124248 54667 20337 20337 1134132 1053706 80426 58911 46038 12873 49096 43679 5417 281755 281755 2367166 2367166 384145 220322 163823 Purchased services 4820903 4307107 513796 Medical supplies 3556178 3541459 14719 Repair & maintenance 1425719 976023 449696 Pharmacy drugs and supp 1172996 1172996 1784796 950348 834448 40691347 34996655 5694692 0 430943 3074 12880823 12071168 5819462 6491131 1322661 1286607 1280934 1231296 79540085 48945372 27080742 30594713 6408046 3272644 431538 1259802 55655149 56210435 4713195 4320221 16630000 16455000 455941 430379 21799136 21205600 X 32581179 33731671 1274834 1273164 33856013 35004835 55655149 56210435 1148822 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 104046 104046 41623326 21047842 20575484 32978823 27014333 5964490 4833890 883197 3950693 30594713 Unamortized premium 430379 430379 X 41840169 0 41840169 0 41840169 40691347 0 40691347 0 40691347 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: Management is not aware of any uncertainties in income tax positions. 1 1 1 X 1 X 100.000000000000 1 1 1 0 0 707540 433733 273807 0.00670 5597173 4591666 1005507 0.02470 6304713 5025399 1279314 0.03140 34721 19820 14901 0.00040 7636784 2329781 5307003 0.13040 17903 0 17903 0.00040 7689408 2349601 5339807 0.13120 13994121 7375000 6619121 0.16260 1 2710683 272010 6823904 10831323 -4007419 X 1 1 1 1 Southwest Medical Center

315 W 15th Street Liberal KS 679011304

X X X Skilled nursing facility Southwest Medical Center 1 1 1 100.000000000000 1 100.000000000000 1 X X X X 1 1 X X 1 X X X X X 0 X X X X X 1 X 0 0 6 Dr Gerald Lane DO

2381 N Kansas Ave Liberal KS 67901

Ophthalmologist Southwest Professional Physicians Clinic

555 W 15th Street Liberal KS 67901

Ortho & ENT Sleep Disorders Laboratory

101 E 11th Street Liberal KS 67901

Sleep Studies North Clinic

2330 N Kansas Ave Suite 1 Liberal KS 67901

Family practice Dr William Valdez MD

2 Plaza Drive Liberal KS 67901

Internal medicine Advanced Surgery

1411 W 15th Street Suite 302 Liberal KS 67901

General Surgeons Part I, Line 7: Amounts for Financial Assistance and Certain Other Community Benefits programs were obtained using known related charges and several cost to charge ratios. The cost to charge ratios used include the overall cost to charge ratio derived from Worksheet 2 as well as individual department cost to charge ratios identified for the calculation of subsidized health services information. Part I, Line 7g: Subsidized Health Services are made up of services that the Hospital provides despite a financial loss to the organization. These services include skilled nursing services, physical therapy, and physician clinics. Part II: N/A Part III, Line 4: The Medical Center 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 Medical Center estimates this allowance based on the aging of its accounts receivable and its historical collection experience for each type of payor.Part III, Line 2Provisions for bad debts are related to accounts that have been deemed uncollectible during the year. The uncollectible amount is then written off pursuant with Hospital policy. The cost of the bad debts reported was determined using the cost to charge ratio and total bad debt expense.Part III, Line 3The estimate of provisions for bad debts attributable to patients eligible under the organization's financial assistance policy was determined using the number of incomplete charity care applications multiplied by the average amount of each account written off pursuant to the organizations financial assistance policy. Part III, Line 8: Amounts were obtained from the cost report filed with Medicare for the period ending December 31, 2012. Part III, Line 9b: The Hospital's collection policy does not contain a provision on the collection practices for patients who are known to qualify for charity care or financial assistance. To be considered for charity care, however, the charity care policy states that the patient must cooperate with the Hospital to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for health care services, such as Medicaid. Then the information is gathered and assessed in order to determine eligibility for charity care. Whenever possible, prior to admission, the Hospital will conduct a pre-admission interview with the patient, the guarantor, and or legal representative. Those patients who may qualify for financial assistance from a governmental program will be referred to the appropriate program, prior to the consideration for charity care. Southwest Medical Center Part V, Section B, Line 14g: Forms of communicating the uncompensated care policy include, but are not limited to:1. Providing information about uncompensated care in patient financial brochures and guest guides in patient rooms.2. Designating Patient Financial Services staff members to explain the uncompensated care policy to the patient.3. Making available to the public a copy of our uncompensated policy, application and eligibility criteria, upon request. Southwest Medical Center Part V, Section B, Line 16e: Garnishments (wage or non-wage) and Writ of Execution Southwest Medical Center Part V, Section B, Line 18e: If patients are denied, the reason is documented in the account notes. Southwest Medical Center Part V, Section B, Line 20d: Southwest Medical Center bills all patients the gross charge amount for the services provided based on a set pricing structure regardless of the patient's payor type. Part VI, Line 2: SWMC conducts a community needs assessment approximately each 3 years. The analysis includes community focus group meetings to hear directly from citizens what they believe are the needs. Additionally, SWMC monitors Kansas Hospital Association patient origin and destination data to look for patterns of migration for services that might be made available locally as a new service. Part VI, Line 3: PFS refers self pay patients to Midland Professionals and Midland assists them in seeing if they are eligible for any federal, state, or local programs. The collectors send out charity care paperwork to patients as they are calling and collecting or if a patient calls for the packet. Part VI, Line 4: SWMC's total service area is rural and is made up of southwest Kansas and the neighboring areas of Oklahoma, Colorado and New Mexico. SWMC's primary service area, however, is Seward County, KS, which has a population of approximately 23,500. According to the U.S. Census Bureau this population is 58% Hispanic with a median household income of $44,550, 16.2% of which are below the Federal poverty level. Seward County, while not designated as a Medically Underserved Area, is designated as a Health Professional Shortage Area based on income. SWMC takes an active role in recruiting needed primary care physicians and specialists to the community that are deemed necessary to provide for the community's needs. SWMC is a County owned hospital and is the only hospital in the county. It therefore provides care to all patients regardless of their ability to pay. 8.5% of services provided by SWMC are provided to Uninsured patients while an additional 15.2% is provided to Medicaid patients. Part VI, Line 5: SWMC's seven Board of Trustees members are appointed by the Seward County Board of County Commissioners. Trustees are required to reside in Seward County, KS, and cannot be employeed by the Hospital nor provide contract services to the Hospital. SWMC extends medical staff privileges to all qualified physicians in the community who so desire to have such privileges.All surplus funds are reinvested back into the Hospital to fund capital needs and additional services that are identified as needed to continue to provide high quality services to the community. SWMC works with other community agencies, including the Seward County Health Department, to provide educational programs to the public throughout the year and an annual Health Fair that provides laboratory testing and health screening to over 589 participants. SWMC provides clinical training facilities for many area educational institutions' nursing, respiratory therapy, and radiology students. This includes Seward County Community College, Fort Hays State University, the University of Kansas, Oklahoma State University, Texas Tech University and others, all without any financial compensation. X X X 1 0 0 0 0 0 0 0 0 William Ermann 150097 0 1247 0 0 0 11797 0 9826 0 172967 0 0 0 Michelle M Gillespie 143913 0 1247 0 0 0 11918 0 4237 0 161315 0 0 0 William R Valdez MD 296628 0 191749 0 0 0 19577 0 9826 0 517780 0 0 0 Lawrence P Shank 481973 0 0 0 0 0 19504 0 9826 0 511303 0 0 0 Eve C Shank 345693 0 0 0 0 0 19927 0 0 0 365620 0 0 0 Rory Howard 283412 0 50000 0 0 0 19754 0 6424 0 359590 0 0 0 Francisco Chacon 177494 0 0 0 0 0 10056 0 5291 0 192841 0 0 0 Norman Lambert 251389 0 0 0 0 0 0 0 9826 0 261215 0 0 0 Part I, Line 4a Norman Lambert, CEO until 12/15/11, recevied $214,914 in gross severance payments in 2012. A Seward County Kansas 486009370 818427ER3 2010-05-27 18167463 Expand and renovate facilities, purchase equipment, and fund debt. 0 0 0 A 1215000 18178316 2602 213246 148667 15063361 1005550 1744619 2012 0 1 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 Schedule K, Part II The difference between Part I, column (e) and Part II, line 3 is due to the accumulation of investment income. X 1 61034 Book value 0 0 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the CFO and the Accounting Manager. Form 990, Part VI, Section B, line 12c A conflict of interest policy disclosure form is provided with a copy of the current conflict of interest policy. This disclosure is completed by each Trustee upon election and annually thereafter. Form 990, Part VI, Section B, line 15 The Board of Trustees is responsible for deteriming the job performance standards for the Administrator/CEO and determining compensation according to the organizations policies. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Financial Statement Reporting Form 990, Part XI, Line 2C The organization has an audit committee that is responsible for the oversight of the financial statement audit and selection of the independent accountant. Southwest Medical Center Foundation PO Box 1340 Liberal KS 67901 480908781 Fundraising for the benefit of Southwest Medical Center KS 501(c)(3) 170(b)(1) 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Southwest Medical Center Foundation C 236034