2012-05-03T11:20:54-05:00 2011-06-30 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS 4063754609 2012-05-03 1 6123764500 2010 2016-02-24 21:20:13Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 47476583 0 X WWW.MDMH.ORG X 1938 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 8 546 169 0 0 163036 225104 47076333 46893051 67705 60140 -80797 -23951 47226277 47154344 0 2644 0 0 23335366 25424585 0 0 187663 20904864 20627165 44240230 46054394 2986047 1099950 45412010 47137440 20273003 20687420 25139007 26450020 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 38228340 2644 46893051 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 48 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL WITH 25 BEDS SETUP. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY AND THERAPY INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, TRANSITIONAL CARE, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS THE ONLY PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY IN WESTERN MONTANA USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. IN 2010, THE HOSPITAL OPERATED FOUR RURAL HEALTH CLINICS. 38228340 1 1 0 0 0 0 0 0 0 1 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 1 0 0 0 0 0 0 1 1 0 0 0 1 67 0 1 546 1 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X DONJA C ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 SONNY LASALLE 4.00 X X 0 0 0 DON LODMELL PHD 4.00 X X 0 0 0 DONNA COONEY 4.00 X 0 0 0 STEVEN ELLIS MD 4.00 X 0 0 0 BARBARA ACKERMAN 4.00 X 0 0 0 BILL BEAN 4.00 X 0 0 0 JAMES OWINGS CPA 4.00 X 0 0 0 MICHAEL COWAN 4.00 X 0 0 0 RANDY STEWART MD 4.00 X 0 0 0 JOHN M BARTOS 40.00 X X 277485 0 29233 WALKER ASHCRAFT MD 40.00 X 152724 0 22698 FREDERIK ILGENFRITZ MD 40.00 X 219002 0 9400 DONJA C ERDMAN 40.00 X 120169 0 19581 JOHN COURCHESNE MD 40.00 X 351250 0 37206 JEREMIAH CLINTON MD 40.00 X 366354 0 5185 JOHN MORELAND MD 40.00 X 317493 0 38500 YVONNE COURCHESNE MD 40.00 X 322413 0 31492 LUKE CHANNER MD 40.00 X 285895 0 28188 2412785 0 221483 30 0 1 0 HEALTHCARE OUTSOURCING NETWORK LLC 621 17TH ST 1800 DENVER CO 80293 BUSINESS SERVICES PROVIDER 450281 ALLIANCE HEALTHCARE SERVICES FILE 55826 LOS ANGELES CA 90074 MRI IMAGING 443682 E-PARTNERS 75 REMITTANCE DR 8617 CHICAGO IL 60675 IT PROFESSIONAL FEES 358282 CLINTON R ADKINS DO 387 WOMBAT CORVALLIS MT 59828 EMERGENCY ROOM PHYSICIAN 254107 CERNER CORPORATION PO BOX 412072 KANSAS CITY MO 64141 IT SUPPORT 226331 9 36500 188604 225104 PATIENT SERVICE INCOME 621400 45239736 45239736 HOSPITAL UTILZTN. REV. 621400 1536465 1536465 OTHER OPERATING INCOME 621400 116850 116850 46893051 109850 109850 171919 261309 -89390 -89390 -89390 11220 60930 -49710 -49710 -49710 MISCELLANEOUS 900099 65439 65439 65439 47154344 46893051 0 36189 2644 2644 818861 400351 418510 19402817 15854546 3444007 104264 105002 95418 8849 735 3786359 3045660 721140 19559 1311546 1048855 255166 7525 64578 64578 49150 49150 4334091 2827351 1494341 12399 175919 175919 4366369 4041137 322710 2522 529456 465937 63519 323507 316812 6695 105554 73593 31918 43 795689 635161 128422 32106 2897824 2605460 285653 6711 959619 959619 PROVISION FOR BAD DEBTS 4872742 4872742 MAINTENANCE AND REPAIRS 718770 564090 152965 1715 MISCELLANEOUS EXPENSES 250553 66270 184199 84 PHARMACY/ LAB EXPENSES 149276 149276 TRAINING & DEVELOPMENT 34068 27499 6569 46054394 38228340 7638391 187663 6104400 3127975 3604899 2592286 8661625 11265092 163929 108523 967188 1079757 453245 370554 48289511 21509276 23527354 26780235 1157713 1368776 771657 444242 45412010 47137440 4077061 5201791 9265000 8685000 5811840 5381512 600007 1119102 819110 20273003 20687420 X 23631082 24723132 524562 743245 983363 983643 25139007 26450020 45412010 47137440 X 1099950 211063 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 3160 3160 313190 313190 4071 4071 313190 313190 313190 0.00000 1.00000 0.00000 0 0 1415098 1415098 29431724 11392672 18039052 695752 606282 89470 16428793 9510322 6918471 318144 318144 26780235 THIRD PARTY SETTLEMENT 819110 819110 47154344 46054394 1099950 211063 211063 1311013 46881091 261309 261309 46619782 534562 534562 47154344 46315703 261309 261309 46054394 0 46054394 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA, AND FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. THE HOSPITAL'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATION TAX RETURNS FOR THE YEARS ENDED 2008 TO 2010 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 1 X 1 X 100.000000000000 1 1 0 1 1 313 343132 343132 0.00750 3665461 4094448 -428987 0.00000 313 4008593 4094448 -85855 0.00750 243403 243403 0.00530 2000 2000 0.00000 6406754 5059809 1346945 0.02920 33444 33444 0.00070 6685601 5059809 1625792 0.03520 313 10694194 9154257 1539937 0.04270 2 2644 2644 0.00010 1 721 721 0.00000 1 77866 77866 0.00170 4 81231 81231 0.00180 1 2534533 0 6359311 12053268 -5693957 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL

1200 WESTWOOD DRIVE HAMILTON MT 59840

X X X X NOT REQUIRED 1 4 CORVALLIS FAMILY MEDICINE CLINIC

1037 MAIN STREET CORVALLIS MT 59828

CLINIC BITTERROOT VALLEY EYE ASSOCIATES

300 N 10TH STREET HAMILTON MT 59840

CLINIC BITTERROOT CLINIC

1224 MAIN STREET HAMILTON MT 59840

CLINIC RAVALLI UROLOGY

1224 MAIN STREET HAMILTON MT 59840

CLINIC PART I, LINE 3C: FULL TO PARTIAL ASSISTANCE MAY BE GRANTED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG, AS ADJUSTED FOR FAMILY SIZE. A FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 CURRENT VALUE. PART I, LINE 6A: A COMMUNITY BENEFIT REPORT FOR FISCAL YEAR 2010 WAS IN THE WINTER 2011 EDITION OF HEALTHLINES, THE NEWSLETTER OF MARCUS DALY MEMORIAL HOSPITAL. THE NEWSLETTER WAS DELIVERED TO EVERY MAILING ADDRESS IN RAVALLI COUNTY COVERING APPROXIMATELY 14,300 HOUSEHOLDS. AN ADDITIONAL 1,000 COPIES OF THE NEWSLETTER WERE PRINTED FOR GENERAL CIRCULATION. PART I, LINE 7: EXPLANATION OF COSTING METHOD:FOR FINANCIAL ASSISTANCE, MEDICAID, COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS,THE HOSPITAL APPLIES THE RATIO OF PATIENT CARE COSTS TO CHARGES (TOTAL OPERATING EXPENSES LESS NON-PATIENT CARE ACTIVITIES, MEDICAID PROVIDER TAXES, TOTAL COMMUNITY BENEFIT AND TOTAL COMMUNITY BUILDING). THIS METHODOLOGY ALSO APPLIES TO EMERGENCY SERVICES, THE BITTERROOT GENERAL VASCULAR SURGERY CLINIC, THE RAVALLI UROLOGY GLINIC, AND BITTERROOT ORTHOPEDICS & SPORTS, ALL INCLUDED IN SUBSIDIZED HEALTH SERVICES. ALSO INCLUDED IN THE SUBSIDIZED HEALTH SERVICES LINE IS HOME HEALTH AND HOSPICE. FOR HOME HEALTH AND HOSPICE, THE MEDICARE COST REPORT WAS USED TO DETERMINE TOTAL COSTS AND REVENUES. 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 $ 4872742. PART II: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. THE HOSPITAL IS ALSO REPRESENTED ON THE BITTERROOT COLLEGE STEERING TEAM AND THE JOB SERVICE ECONOMIC COUNCIL. THE HOSPITAL PARTNERS WITH THE ROCKY MOUNTAIN LAB, A LEVEL 4 BIOHAZARD LAB, TO HELP ENSURE COMMUNITY SAFETY AND IS REPRESENTED AT ADULT PROTECTION SERVICES AND OTHER COMMUNITY SUPPORT ORGANIZATIONS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT RECEIVABLES" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"THE HOSPITAL MAINTAINS AN ALLOWANCE FOR UNCOLLECTIBLE SELF-PAY ACCOUNTS. PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED AT THE TIME OF SERVICE WHEN THE AMOUNT DUE IS KNOWN OR UPON RECEIPT OF AN INVOICE, AFTER PAYMENT BY INSURANCE, IF ANY. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. WHEN ALL COLLECTION EFFORTS HAVE BEEN EXHAUSTED, THE ACCOUNT IS WRITTEN OFF AGAINST THE RELATED ALLOWANCE."THE AMOUNT OF BAD DEBT EXPENSE (AT COST) REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT 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 PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF $5 MILLION. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. IRS AND CLIFTONLARSONALLEN METHODOLOGY WAS USED TO COMPUTE THE MEDICARE SHORTFALL. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PATIENT FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE CHARITY CARE COMMITTEE FOR REVIEW AND DETERMINATION OF CHARITY CARE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $30 MUST BE PAID MONTHLY, WITH THE BALANCE PAID IN FULL WITHIN 3 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: PLANNING IS IN PLACE TO DEVELOP CRITERIA FOR ASSESSING THE NEEDS OF THE COMMUNITY IN WHICH THE HOSPITAL SERVES. NEEDS ASSESSMENT CRITERIA WILL BE IN USE FOR FISCAL YEAR 2013. PART VI, LINE 3: BILLING AND COLLECTION INFORMATION IS LOCATED ON THE BACK OF STATEMENTS SENT TO PATIENTS. ON A MONTHLY BASIS, WE CONTACT BY PHONE REQUESTING PAYMENT AND MAY EXPLAIN POLICIES AT THAT TIME. WE UTITLIZE THE MASH PROGRAM TO SCREEN PRIVATE PAY PATIENTS TO QUALIFY FOR OTHER PROGRAMS SUCH AS MEDICAID AND DISABILITY. PART VI, LINE 4: WE SERVE A RURAL POPULATION WHERE THE HOUSEHOLD MEDIAN INCOME IS ABOUT $28,000. OUR PAYER MIX IS 50% MEDICARE, 9% MEDICAID, 11% SELF PAY, NO INSURANCE, WITH THE BALANCE AS OTHER COMMERCIAL PAYERS. THE PERIOD UNEMPLOYMENT RATE IN RAVALLI COUNTY IS BETWEEN 9 AND 10.2%. PART VI, LINE 6: THE HOSPITAL IS PROUD OF IT'S EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS THROUGH PROMOTING WOMEN'S HEART HEALTH AND BREAST CANCER AWARENESS. THE HOSPITAL SPONSORS AN ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICAL ACTIVITIES. OTHER COMMUNITY CLINICS OR SCREENINGS INCLUDED BLOOD PRESSURE TESTING AT AREA SENIOR CENTERS, AND LIPID PROFILES AND CHOLESTEROL TESTS PROVIDED TO THE COMMUNITY FREE OF CHARGE. THE HOSPITAL WAS PROUD TO CONDUCT AN EDUCATIONAL SERIES DEDICATED TO DIABETES WHICH WAS WELL RECEIVED BY THE COMMUNITY. PART VI, LINE 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 MT X X X 0 0 0 0 0 0 0 0 0 JOHN M BARTOS 233412 0 0 0 44073 0 20520 0 8713 0 306718 0 0 0 WALKER ASHCRAFT MD 132001 0 20723 0 0 0 15984 0 6714 0 175422 0 0 0 FREDERIK ILGENFRITZ MD 219002 0 0 0 0 0 8400 0 1000 0 228402 0 0 0 JOHN COURCHESNE MD 184452 0 166798 0 0 0 30492 0 6714 0 388456 0 0 0 JEREMIAH CLINTON MD 366354 0 0 0 0 0 0 0 5185 0 371539 0 0 0 JOHN MORELAND MD 271844 0 45649 0 0 0 38500 0 0 0 355993 0 0 0 YVONNE COURCHESNE MD 163708 0 158705 0 0 0 30492 0 1000 0 353905 0 0 0 LUKE CHANNER MD 249999 0 35896 0 0 0 18500 0 9688 0 314083 0 0 0 MT HEALTH FACILITY AUTHORITY 810302402 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 750000 7135000 538116 261801 5973474 2008 1 0 1 1 0 0 0 0 1 0 0 0 0 0 0 KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 104607 EMPLOYMENT 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED, IN DETAIL, BY THE CFO AND CEO. THE FORM 990 WAS THEN REVIEWED BY THE BOARD OF DIRECTORS AND HOSPITAL FINANCE COMMITTEE AT A BOARD MEETING BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL ATTORNEY ATTENDS ALL BOARD MEETINGS AND HE IS GIVEN THE AUTHORITY TO QUESTION, PRIOR TO DISCUSSION, A POTENTIAL CONFLICT OF INTEREST FOR ANY DIRECTOR. THE CEO RAISES A QUESTION REGARDING CONFLICT OF INTEREST. THE HOSPITAL BOARD ASKS THE DIRECTOR TO STEP OUT OF THE ROOM DURING DISCUSSION OF CONFLICT. THE DIRECTOR IS EXCUSED FOR THE DISCUSSION ONCE A CONFLICT HAS BEEN DETERMINED OR IS INVITED BACK INTO THE ROOM IF NO CONFLICT IS DETERMINED TO EXIST. FORM 990, PART VI, SECTION B, LINE 15 CEO - OCCURS ANNUALLY WITH ANNUAL COMPENSATION COMMITTEE OF THE BOARD. THE COMMITTEE REVIEWS SURVEYS FOR COMPARABLE PAY AND BENEFITS. THIS COMMITTEE ALSO CONDUCTS THE ANNUAL EVALUATION OF THE CFO. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 211,063. TOTAL TO FORM 990, PART XI, LINE 5: 211,063. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) 11-TYPE 2 N/A 1 0 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 DALY HOSPITAL FOUNDATION INC K 145953 FAIR MARKET VALUE