2012-05-14T10:35:58-05:00 2011-06-30 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2010-07-01 440629397 Carroll County Memorial Hospital CARR 6605421695 1502 N Jefferson St Carrollton MO 64633 Jeff Tindle 6605421695 2012-05-10 1 Gary D Knoll 7852334226 2012-05-10 2010 2016-02-24 21:20:13Z Jeff Tindle 1502 N Jefferson St Carrollton MO 64633 12653964 0 X N/A X 1957 MO Carroll County Memorial Hospital is an acute care hospital providing inpatient and outpatient medical care regardless of ability to pay. 9 9 190 0 0 0 8960 1740 12629286 12289337 224828 198503 121255 164159 12984329 12653739 0 2500 0 0 6870281 7063626 0 0 0 5387191 6015750 12257472 13081876 726857 -428137 22779169 23189013 1049342 1624253 21729827 21564760 To improve the health of the community by assuring excellent medical care to our citizens. 0 0 10038057 12289337 Acute care hospital organized to provide inpatient and outpatient care to area residents regardless of their ability to pay. 10038057 1 0 0 0 0 0 0 0 0 1 1 0 0 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 12 0 1 190 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 Edward E Butts 4.00 X X 0 0 0 Stanley Kruse 4.00 X X 0 0 0 Rex Buhrmester 4.00 X X 0 0 0 Carolyn Lock 4.00 X 0 0 0 Linda Ross 4.00 X 0 0 0 Dick Woodward 4.00 X 0 0 0 Donald Kampschmidt 4.00 X 0 0 0 Randall Barry 4.00 X 0 0 0 Debbie Minnick 4.00 X 0 0 0 Jerry Dover 40.00 X 163733 0 17894 Jeffrey Tindle 40.00 X 116520 0 14117 Waclaw ADymek 40.00 X 173206 0 18652 Julie Marvin 40.00 X 115680 0 9254 Richard Smith 40.00 X 173523 0 25080 Tim Reid 40.00 X 137740 0 10680 880402 0 95677 6 0 1 0 Clinishare Inc 19600 E 39th Street Independence MO 64057 Nuclear Medicine 259334 Cerner Corporation PO Box 412702 Kansas City MO 64141 Computer Systems 221280 HSMC Technology Services Inc 3550 NE Ralph Powell Rd Lees Summit MO 64064 IT Service 185883 Richard L Smith MD 20644 HWY Z Chillicothe MO 64601 ER Physician Coverage 142907 Emcare Physician Services 7032 Collection Center Dr Chicago IL 60693 ER Physician Coverage 137099 6 1740 1740 Net Patient service re 621990 12289337 12289337 12289337 198728 198728 60000 60000 60000 60000 225 -225 -225 -225 Other income 900099 86606 86606 Vending 900099 7928 7928 Medical record fees 621990 5168 5168 4457 4457 104159 12653739 12289337 0 362662 2500 2500 329346 329346 5396414 4565141 831273 308865 266687 42178 636971 518772 118199 392030 313636 78394 9000 14 8986 954882 898447 56435 19753 7876 11877 31188 31188 42850 5574 37276 441690 141368 300322 57280 51314 5966 1236938 1236938 161810 161810 Collection fees and bad 979766 979766 Medicaid FRA Tax 422016 422016 Supplies 407033 344490 62543 Pharmaceuticals 341998 341998 Repairs and maintenance 186372 113852 72520 723174 218496 504678 13081876 10038057 3043819 0 7533874 8223551 1596950 1186139 117529 119724 101789 90850 19456734 9008657 10566312 10448077 2306776 1969846 555939 1150826 22779169 23189013 1026725 1157222 22617 467031 1049342 1624253 X 21729827 21564760 21729827 21564760 22779169 23189013 X -428137 263070 X X 0 1 1 X 0 X 19456734 9008657 10448077 10448077 Equity securities 1173194 F Corporate bonds 796652 F 1969846 Property and equipment purchases payable 84815 Purchase agreement 382216 467031 12653739 13081876 -428137 263070 263070 -165067 12653739 0 12653739 0 12653739 13081876 0 13081876 0 13081876 1 1 1 X 1 X 1 0 1 1 159734 84845 74889 0.00620 1726095 1132030 594065 0.04900 1885829 1216875 668954 0.05520 5000 5000 0.00040 1000 1000 0.00010 3894892 2459290 1435602 0.11850 935 935 0.00010 3901827 2459290 1442537 0.11910 5787656 3676165 2111491 0.17430 1 593481 392469 4719487 4673659 45828 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 1 X X 1 X X X 1 X X X X X X X X 1 X 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 $ 967527. 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, 2011. 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: Patient visits with a financial counselor to determine payment ability. 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 Hospital's 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 9,500 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 Chillicothe, Marshall, Lexington, and Richmond. The distance between Carroll County Memorial Hospital and all of these facilities are approximately 30 miles. Part VI, Line 6: 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 163733 0 0 0 0 0 13214 0 4680 0 181627 0 84492 0 Waclaw ADymek 173206 0 0 0 0 0 13972 0 4680 0 191858 0 81911 0 Richard Smith 173523 0 0 0 0 0 14400 0 10680 0 198603 0 94525 0 Andrew Horine Medical School X 60000 60000 0 1 1 60000 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 filling. 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 263,070. Financial Statements FORM 990, PART XII, LINE 2c The Carrol County Memorial Hospital Board along with Administration assumes responsibility.