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Okmulgee Memorial Hospital Inc: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
Okmulgee Memorial Hospital Inc (EIN 73-1279909)
Tax period
2011-01-01 to 2011-12-31
Filed
2012-11-14
IRS object ID
201203199349304860
Schema version
2011v1.2
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)
Timestamp2012-11-14T14:20:32-06:00Timestamp
Tax Period End Date2011-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN450250958EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1EIDE BAILLY LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line11601 NW ExpresswayAddressLine1
CityOklahoma CityCity
StateOKState
ZIP Code73118ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN731279909EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1Okmulgee Memorial Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlOKMUNameControl
Phone9187564233Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line11401 Morris DriveAddressLine1
CityOkmulgeeCity
StateOKState
ZIP Code74447ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameDoran HammettName
TitleChief Financial OfficerTitle
Phone9187564233Phone
Date Signed2012-11-14DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameCarolyn LevingsName
PTINP01083874PTIN
Phone4054783334Phone
Date Prepared2012-11-14DatePrepared
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonGeorge MillerNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line11401 Morris DriveAddressLine1
CityOkmulgeeCity
StateOKState
ZIP Code74447ZIPCode
FieldValueIRS element (for citing)
Gross Receipts20339974GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web Sitehttp://www.okmulgeehospital.comWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1967YearFormation
State Legal DomicileOKStateLegalDomicile
Activity Or Mission DescriptionHealth Care ServicesActivityOrMissionDescription
Nbr Voting Members Governing Body10NbrVotingMembersGoverningBody
Nbr Independent Voting Members10NbrIndependentVotingMembers
Total Nbr Employees338TotalNbrEmployees
Total Nbr Volunteers117TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year200529ContributionsGrantsPriorYear
Contributions Grants Current Year42462ContributionsGrantsCurrentYear
Program Service Revenue Prior Year20243573ProgramServiceRevenuePriorYear
Program Service Revenue CY20281130ProgramServiceRevenueCY
Investment Income Prior Year883InvestmentIncomePriorYear
Investment Income Current Year833InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year20444985TotalRevenuePriorYear
Total Revenue Current Year20324425TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year10494101SalariesEtcPriorYear
Salaries Etc Current Year10325107SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year10957572OtherExpensePriorYear
Other Expenses Current Year10530185OtherExpensesCurrentYear
Total Expenses Prior Year21451673TotalExpensesPriorYear
Total Expenses Current Year20855292TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-1006688RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-530867RevenuesLessExpensesCY
Total Assets BOY5373192TotalAssetsBOY
Total Assets EOY5921754TotalAssetsEOY
Total Liabilities BOY4461351TotalLiabilitiesBOY
Total Liabilities EOY5540780TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY911841NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY380974NetAssetsOrFundBalancesEOY
Mission DescriptionOkmulgee Memorial Hospital's mission is to put our patients and customers first and to provide quality health care in an efficient manner.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense17051324Expense
Revenue20281130Revenue
DescriptionOkmulgee Hospital is a sixty-six bed hospital facility providing such services as, but not limited to, Inpatient, Outpatient, Psychiatric, Home Health and Emergency Care services to the general public regardless of ability to pay.The Hospital provided $254,722 of charity care in 2011.Description
Total Program Service Expense17051324TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization1BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109612NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees338NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members10NbrVotingGoverningBodyMembers
Number Independent Voting Members10NumberIndependentVotingMembers
Family Or Business Relationship1FamilyOrBusinessRelationship
Delegation Of Management Duties1DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees0MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledOKStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1Doran HammettBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number9187583102TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11401 Morris DriveAddressLine1
CityOkmulgeeCity
StateOKState
ZIP Code74447ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (13 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationKey EmployeeKeyEmployeeHighest Compensated EmployeeHighestCompensatedEmployee
John Fidler
President1.00XX000
Nevyle Cable
President-Elect1.00XX000
Barbara Osborn
Secretary1.00XX000
Greg Marriott
Treasurer1.00XX000
Tracy Sanford DO
Trustee1.00X000
Timothy Sandford DO
Trustee1.00X000
Linda Janzen
Trustee1.00X000
Walter McGown OD
Trustee1.00X000
Jason Winters
Trustee1.00X000
R Stanley White MD
Trustee1.00X000
Paul Ervin
CFO40.00X7037100
Jason Bruce
CRNA40.00269804016500X
Benjamin Kamp DO
Surgeon40.00309952016500X
FieldValueIRS element (for citing)
Total Reportable Comp From Org650127TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation33000TotalOtherCompensation
Number Individuals GT100 K2NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
Quorum Health Resources
105 Continental PlBrentwoodTN37027ER Physicians545436
Horizon Health
PO Box 840839DallasTX75284Mental Health488283
Cardinal Health Pharmacy
P O BOX 847384DallasTX75284Supplies/Med & Pharmacy416304
Cardinal Health
PO Box 847384DallasTX75284Supplies/Med & Pharmacy325524
CPSI
PO Box 850309MobileAL36695Internet & Computer Serv.305438
FieldValueIRS element (for citing)
Number Of Contractors GT100 K5NumberOfContractorsGT100K
Government Grants42462GovernmentGrants
Total Contributions42462TotalContributions

Program Service Revenue ProgramServiceRevenue (5 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
Net Patient Serv. Rev.6241001936469219364692
Miscellaneous Revenue900099805464805464
Dietary9000998182681826
Maint. & Janitorial9000992317823178
Security Services90009959705970
FieldValueIRS element (for citing)
Total Program Service Revenue20281130TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column483TotalRevenueColumn
Exclusion$483ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities15899Securities

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities15549Securities

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities350Securities

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column350TotalRevenueColumn
Exclusion$350ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column20324425TotalRevenueColumn
Related Or Exempt Function Income20281130RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$833ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total683127Total
Program Services612756ProgramServices
Management And General70371ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total7361715Total
Program Services5689934ProgramServices
Management And General1671781ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total79260Total
Program Services54849ProgramServices
Management And General24411ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total1579248Total
Program Services1235845ProgramServices
Management And General343403ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total621757Total
Program Services486558ProgramServices
Management And General135199ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total51049Total
Management And General51049ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total57804Total
Management And General57804ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total2152941Total
Program Services1875184ProgramServices
Management And General277757ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1507378Total
Program Services732384ProgramServices
Management And General774994ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total10177Total
Program Services4167ProgramServices
Management And General6010ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total315688Total
Program Services304425ProgramServices
Management And General11263ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total65592Total
Program Services53506ProgramServices
Management And General12086ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total136565Total
Management And General136565ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total613011Total
Program Services459758ProgramServices
Management And General153253ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total285322Total
Program Services238321ProgramServices
Management And General47001ManagementAndGeneral

Other Expenses OtherExpenses (3 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
Bad debt expense40132844013284
Supplies12132931213293
Recruitment2615026150

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total81931Total
Program Services77060ProgramServices
Management And General4871ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total20855292Total
Program Services17051324ProgramServices
Management And General3803968ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY14718BOY
EOY86569EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY2103925BOY
EOY2634983EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY787769BOY
EOY715222EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY233876BOY
EOY424204EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis12866706LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec10805930LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY2232904BOY
EOY2060776EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY5373192BOY
EOY5921754EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY2360125BOY
EOY3008084EOY

Deferred Revenue DeferredRevenue

FieldValueIRS element (for citing)
EOY33172EOY

Unsecured Notes Loans Payable UnsecuredNotesLoansPayable

FieldValueIRS element (for citing)
BOY2020985BOY
EOY2022821EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY80241BOY
EOY476703EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY4461351BOY
EOY5540780EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY911841BOY
EOY380974EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY911841BOY
EOY380974EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY5373192BOY
EOY5921754EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses-530867ReconcilationRevenueExpenses
Reconcilation Other Changes0ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required0FederalGrantAuditRequired

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 D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis22716OtherCostOrOtherBasis
Book Value22716BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis5305423OtherCostOrOtherBasis
Depreciation4759423Depreciation
Book Value546000BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis102260OtherCostOrOtherBasis
Depreciation102260Depreciation
Book Value0BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis7436307OtherCostOrOtherBasis
Depreciation5944247Depreciation
Book Value1492060BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings2060776TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionEstimated Third Party SettlementsDescription
Amount$476,703Amount
FieldValueIRS element (for citing)
Total Of Amounts476703TotalOfAmounts
Total Revenue20324425TotalRevenue
Total Expenses20855292TotalExpenses
Excess Or Deficit For Year-530867ExcessOrDeficitForYear
Excess Or Deficit Per FS-530867ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt20281963TotRevenueEtcAuditedFinclStmt
Revenue Not Rptd F9900RevenueNotRptdF990
Revenue Subtotal20281963RevenueSubtotal
Other Revenues Not Included42462OtherRevenuesNotIncluded
Revenue Not Rptd On Fin Stmt42462RevenueNotRptdOnFinStmt
Total Revenue Per Form99020324425TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt20855292TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal20855292ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99020855292TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (2 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
Description of Uncertain Tax Positions Under FIN 48:Part X:The Hospital undergoes an annual analysis of its various tax positions assessing the likelihood of these positions being upheld upon examination with relevant tax authorities, as defined by the accounting principles generally accepted in the United States of America. (GAAP). The Hospital believes that they are compliant with all IRS tax regulations and as of December 31, 2011 have not recorded any unrecognized tax benefit or liabilities for income taxes.
Part XII, Line 4b - Other Adjustments:Capital Contributions Not included in Total Revenue

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
Policy Applied To All HospitalsXPolicyAppliedToAllHospitals
FPG Reference Free Care1FPGReferenceFreeCare
Pcent200XPcent200
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent250XPcent250
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget0ExpensesExceededBudget
Annual Community Benefit Report0AnnualCommunityBenefitReport

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense117000TotalCommunityBenefitExpense
Net Community Benefit Expense117000NetCommunityBenefitExpense
Percent Of Total Expense0.00690PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense3300884TotalCommunityBenefitExpense
Direct Offsetting Revenue1671747DirectOffsettingRevenue
Net Community Benefit Expense1629137NetCommunityBenefitExpense
Percent Of Total Expense0.09670PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense3417884TotalCommunityBenefitExpense
Direct Offsetting Revenue1671747DirectOffsettingRevenue
Net Community Benefit Expense1746137NetCommunityBenefitExpense
Percent Of Total Expense0.10360PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense3417884TotalCommunityBenefitExpense
Direct Offsetting Revenue1671747DirectOffsettingRevenue
Net Community Benefit Expense1746137NetCommunityBenefitExpense
Percent Of Total Expense0.10360PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported0BadDebtExpenseReported
Bad Debt Expense$4,013,284BadDebtExpenseAmount
Amount Attributable To25017AmountAttributableTo
Amount Reimbursed By Medicare8068192AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare8184590CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall-116398MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
OtherXOther
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care0ProvisionForCharityCare
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 Line1Okmulgee Memorial HospitalBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line11401 Morris DriveAddressLine1
CityOkmulgeeCity
StateOKState
ZIP Code74447ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Er24 HoursXEr24Hours
OtherPsych-16 BedsOther

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1Okmulgee Memorial Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent200.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent250.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
Medical IndigencyXMedicalIndigency
Explains Application Method1ExplainsApplicationMethod
Includes Publicity Measures1IncludesPublicityMeasures
Available On RequestXAvailableOnRequest
Other PublicityXOtherPublicity
Actions On Nonpayment1ActionsOnNonpayment
Collection Activities0CollectionActivities
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Used Other MethodXUsedOtherMethod
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges0GrossCharges

Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC

FieldValueIRS element (for citing)
Number Of Other Facilities2NumberOfOtherFacilities

Other Facilities OtherFacilities (2 entries)

Address Line1Address/AddressLine1CityAddress/CityStateAddress/StateZIP CodeAddress/ZIPCodeFacility TypeFacilityType
Home Health Agency
1401 Morris DriveOkmulgeeOK744476419In-Home Care Service
Benjamin A Kamp DO
1201 S Belmont Ste 207OkmulgeeOK744476419Clinic

Form990 Schedule H Part VI Form990ScheduleHPartVI (11 entries)

ExplanationExplanationIdentifierIdentifier
Part I, Line 7: Charity care was converted to cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments.Unreimbursed Medicaid was calculated using the cost-to-charge ratio derived from Worksheet 2.
Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $4,013,284.
Part III, Line 4: Bad debt is determined by our bad debt policy considering actual patient care charges. Charges become bad debt once a reasonable opportunity has been made by the hospital to collect an open account and the responsible party has been contacted regarding the unpaid balance. After policy based collection attempts have been exhausted, the account is written off to bad debt.All payments and contractual are applied to the account before it is written off to bad debt. If any payments are received for bad debts that have been written off, they are applied to the current year bad debt expense.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges.The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision.
Part III, Line 8: Total revenue received from Medicare (including DSH and IME) is the gross reimbursement plus settlement (including LSA). Both the total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.
Part III, Line 9b: The hospital has a charity care policy and patients must meet certain established criteria for charity service consistent with OHM's mission. The policy does not specifically state the collection procedures for those who qualify for other financial assistance which most would be Medicaid. The hospital does have provisions but they are not specifically written in the policy. No collections actions are filed while an application is in review, any personal portion due after a determination of assistance would follow normal collections practices.
Part V, Section B, Line 13g: The financial assistance policy is available to obtain from the patient Financial Counselor.Okmulgee Memorial Hospital, Inc.
Part V, Section B, Line 19d: The hospital is in the process of establishing a new plan to follow to be in compliance with the new 501(r) requirements. The probable method to use for FAP-eligible individuals will be the Medicare fee-for-service plan.Okmulgee Memorial Hospital, Inc.
Part VI, Line 2: Okmulgee Memorial Hospital has a strategic plan and looks at information provided by the state, county and Medicare. The hospital looks at discharges, hospitalization and utilization of different categories of patients. The information is used to assess physician needs as well as the purchasing of capital equipment. The hospital also participates in the County Wellness Coalition. Information from surveys are used in the needs assessment for the hospital.
Part VI, Line 3: The hospital uses an electronic program at admission to determine if a patient is eligible for assistance. If a patient is determined to be eligible, then the patient is referred to a financial counselor. The financial counselor works with the patient to determine if the patient is eligible for Medicaid. If the patient is not eligible for Medicaid, the hospital then works with the patient to determine if the patient is eligible for charity care. The Financial Counselor contact information is included in the patient billing statements if further assistance is needed.
Part VI, Line 4: Okmulgee Memorial Hospital is an acute care hospital located in Okmulgee, which is in Okmulgee County, Oklahoma. Okmulgee County is a federally underserved area according to the Health Resources and Services Administration. Okmulgee is a small community of about 13,000 residents. There are two other hospitals in the county with one about twenty miles from Okmulgee Memorial Hospital. The median household income is $35,615 and 19.2% of families and 21.4% of individuals of the population are below the poverty line.
Part VI, Line 5: The organization has a volunteer board comprised of members of the community. Medical staff privileges are extended to all qualified physicians in the community and to those who wish to render services at OMH. Any surplus funds, if available, are reinvested in the facilities to improve patient care.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (2 entries)

Base 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 OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
Jason Bruce
2698040000016500000286304000
Benjamin Kamp DO
3099520000016500000326452000

Schedule L IRS990ScheduleL

Form990 Schedule L Part IV Form990ScheduleLPartIV

Name Of Interested Person NameOfInterestedPerson

FieldValueIRS element (for citing)
Name PersonTracey Timothy SanfordNamePerson
FieldValueIRS element (for citing)
RelationshipBoard DirectorsRelationship
Amount Of Transaction41651AmountOfTransaction
Description Of TransactionLeases medical office space from a related organization, Okmulgee Medical Foundation, Inc.DescriptionOfTransaction
Sharing Of Revenues0SharingOfRevenues

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (7 entries)

Return ReferenceReturnReferenceExplanationExplanation
Form 990, Part VI, Section A, line 2Tracy & Timothy Sanford (Trustees) - family relationship
Form 990, Part VI, Section A, line 3Management duties include planning and executing financial operations. Quorem Health Resources manages the hospital.
Form 990, Part VI, Section A, line 8bThe organization does not have a committee with authority to act on behalf of the governing body.
Form 990, Part VI, Section B, line 11The Form 990 is prepared by an outside accounting firm and is reviewed internally by the CEO and the Finance Committee prior to filing with the IRS. The Board of Directors is provided a copy.
Form 990, Part VI, Section B, line 12cWe also have a conflict of interest policy which is applicable to all employees of OMH. Once a potential conflict is identified, Compliance and administration determine the level and risk of the conflict. Depending on the severity of conflict an employee may be asked to refrain involvement. If there is a known conflict that is not disclosed by an employee, they will be subject to the disciplinary action policy.
Form 990, Part VI, Section B, line 15The Board of Directors reviews and approves salaries of top management positions. Salary determination is based on comparability data from industry standards. CEO compensation is recommended by Quorem Health Resources and Board approved.
Form 990, Part VI, Section C, line 19The organization makes its governing documents, conflict of interest policy, and financial statemsnts available to the public upon request.

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1Okmulgee Medical Foundation IncBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1PO Box 1038AddressLine1
CityOkmulgeeCity
StateOKState
ZIP Code74447ZIPCode
FieldValueIRS element (for citing)
EIN730766656EIN
Primary ActivitiesOffice building and manages tax deductible contributionsPrimaryActivities
Legal Domicile StateOKLegalDomicileState
Exempt Code Section501(c)(3)ExemptCodeSection
Public Charity Status509(a)(1)PublicCharityStatus
Controlled Org0ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org1LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs1PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable

Name Of Other Organization NameOfOtherOrganization

FieldValueIRS element (for citing)
Business Name Line1Okmulgee Medical FoundationBusinessNameLine1
FieldValueIRS element (for citing)
Transaction TypeKTransactionType
Amount Involved60804AmountInvolved
Method Of Amt DeterminationFMVMethodOfAmtDetermination