2012-04-26T11:58:10-05:00 2011-06-30 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2010-07-01 860208451 NORTHERN COCHISE COMMUNITY HOSPITAL INC NORT 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ROLAND KNOX 5203843541 2012-04-26 1 5206248229 2010 2016-02-24 21:20:13Z ROLAND KNOX 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 18661097 0 X WWW.NCCH.COM X 1966 AZ TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 6 6 192 68 0 0 1436322 1806974 15945796 16812834 27690 -262033 32035 40503 17441843 18398278 0 7000 0 0 10880994 10600063 0 0 0 7889459 7288462 18770453 17895525 -1328610 502753 8414499 7192570 6779789 5055107 1634710 2137463 TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 0 0 13470810 16812834 THE HOSPITAL PROVIDES HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF AGE, RACE, OR ABILITY TO PAY. SERVICES INCLUDE, BUT ARE NOT LIMITED TO EMERGENCY ROOM, PHYSICAL THERAPY, SPEECH THERAPY, RESP THERAPY, CT SCAN, MRI, NURSING HOME SERVICES, RURAL HEALTH CLINIC, AND OTHER SERVICES. 13470810 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 43 0 1 192 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 AZ X X THE ORGANIZATION 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ANSELMO TORRES 1.00 X 0 0 0 CAROL DUNAGAN 1.00 X 0 0 0 SHIRLEY SHOTTEN 1.00 X 0 0 0 KAY HAAS 1.00 X 0 0 0 RAYMOND SCOTT 1.00 X 0 0 0 KATHY COOK 1.00 X 0 0 0 RICHARD H SMITH 40.00 X 245426 0 23338 JOHN R MUNSON 40.00 X 109380 0 11447 HENRY JWEDIG JR 36.00 X 155157 0 35575 JEFFERY B BUSHMAN 28.00 X 343093 0 24977 MARA OKSHTEYN 32.00 X 210353 0 22697 JOHN M FEENEY 36.00 X 108588 0 7486 SARAH D WILSON 40.00 X 106658 0 43446 1278655 0 168966 7 0 1 0 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 ER PHYSICIANS 602897 SHARED IMAGING INC PO BOX 88544 MILWAUKEE WI 53295 RADIOLOGY 471060 ELHAM MEDICAL INTERNATIONAL INC PO BOX 12578 TUCSON AZ 85732 HOSPITALIST 347850 ALLIANCE HEALTHCARE SERVICES FILE 55826 LOS ANGELES CA 90074 RADIOLOGY 288584 US TELERADIOLOGY 1175 PEACHTREE STREET STE 1425 ATLANTA GA 30361 RADIOLOGY 265943 13 1581392 187393 38189 1806974 PATIENT SERVICE REVENU 900099 16771473 16771473 OTHER SERVICE REVENUE 900099 41361 41361 16812834 786 786 40503 40503 40503 40503 262819 -262819 -262819 -262819 18398278 16812834 0 -221530 7000 7000 340672 238470 102202 7830849 5481594 2349255 138070 96649 41421 1727278 1209095 518183 563194 394236 168958 108924 69891 39033 74857 48032 26825 1449972 930377 519595 2940 2333 607 20062 17791 2271 42025 33345 8680 65309 45716 19593 182287 182287 661836 590844 70992 349571 349571 MATERIALS AND SUPPLIES 1151479 1124818 26661 RENT-EQUIPMENT 795978 771266 24712 OUTSIDE SERVICES 654594 519389 135205 REPAIRS AND MAINTENANCE 451445 358200 93245 UTILITIES 238125 188941 49184 1039058 810965 228093 17895525 13470810 4424715 0 2328086 1314709 245648 93620 2360272 2250000 141932 151595 109712 174799 6330746 3161410 3210349 3169336 18500 38511 8414499 7192570 2189434 2312291 2245912 2148899 2344443 593917 6779789 5055107 X 1597399 2071867 37311 65596 1634710 2137463 8414499 7192570 502753 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1462971 495846 967125 311026 78725 232301 4074498 2586839 1487659 482251 482251 3169336 ESTIMATED AMOUNTS DUE TO THIRD PARTY PAYERS 593917 593917 1 1 X 1 X 0 0 0 0 45323 45323 0.00280 4752821 3819877 932944 0.05870 4798144 3819877 978267 0.06150 1748 1748 0.00010 1748 1748 0.00010 4799892 3819877 980015 0.06160 162736 95000 67736 0.00430 162736 95000 67736 0.00430 1 1716933 4230874 6416235 -2185361 X 1 0 1 1 NORTHERN COCHISE COMMUNITY HOSPITAL

901 REX ALLEN DR WILLCOX AZ 85643

X X X X NORTHERN COCHISE COMMUNITY HOSPITAL 1 1 1 100.000000000000 0 1 X X X X X 1 1 X 1 X 1 X X X 1 X 0 0 6 SULPHUR SPRINGS MEDICAL CENTER

900 W SCOTT WILLCOX AZ 85643

MEDICAL CENTER NORTHERN COCHISE NURSING HOME

901 REX ALLEN DR WILLCOX AZ 85643

NURSING HOME SUNSITES MEDICAL CENTER

223 N FRONTAGE RD PEARCE AZ 85625

MEDICAL CENTER SPECIALTY CLINICS

900 W SCOTT WILLCOX AZ 85643

CLINIC SENIOR BEHAVIORAL HEALTH CENTER

901 REX ALLEN DR WILLCOX AZ 85643

MEDICAL CENTER SAM SIMON CLINIC

901 REX ALLEN DR WILLCOX AZ 85643

CLINIC PART I, LINE 3C: THE ORGANIZATION PROVIDES DISCOUNTED CARE BASED ON A CASE BY CASE EVALUATION. ALL INFORMATION IS REVIEWED BY THE PFS DIRECTOR AND COMPARED WITH THE POVERTY GUIDELINES AS WELL AS ALL OUTSTANDING MEDICAL EXPENSES. OTHER FACTORS WILL CONTRIBUTE TO THE FINAL DECISION. 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 $ 1988616. NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL UTILIZES THE STANDARD CHARGES THAT ARE APPLIED FOR ALL PATIENTS REGARDLESS OF PAYER. 1 SCHOLARSHIP 6 7000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS A SCHOLARSHIP FUND WHICH IS SEPARATE AND APART FROM THE OPERATING FUNDS AND IS USED EXCLUSIVELY FOR SCHOLARSHIP PURPOSES. THE CHIEF FINANCIAL OFFICER (CFO) OR DESIGNEE SHALL MAINTAIN FINANCIAL RECORDS OF THE SCHOLARSHIP FUND AND PROVIDE AN ANNUAL REPORT TO THE GOVERNING BOARD AS WELL AS SEMI-ANNUAL OR QUARTERLY REPORTS TO THE SCHOLARSHIP COMMITTEE. X X X X 0 0 0 1 0 1 0 0 0 RICHARD H SMITH 216176 0 29250 0 0 0 4994 0 7735 0 258155 0 0 0 HENRY JWEDIG JR 144539 0 10618 0 0 0 4280 0 14484 0 173921 0 0 0 JEFFERY B BUSHMAN 296969 0 46124 0 0 0 6230 0 6788 0 356111 0 0 0 MARA OKSHTEYN 195765 0 14588 0 0 0 4580 0 7828 0 222761 0 0 0 SARAH D WILSON 82504 0 24154 0 0 0 2136 0 20122 0 128916 0 0 0 PART I, LINE 5 PURSUANT TO THE EMPLOYEE AGREEMENT WITH FORMER CEO, AN INCENTIVE WAS PAID BASED ON THE ORGANIZATION'S REVENUE AND EARNINGS. PART I, LINE 6 PURSUANT TO THE EMPLOYEE AGREEMENT WITH FORMER CEO, AN INCENTIVE WAS PAID BASED ON THE ORGANIZATION'S REVENUE AND EARNINGS. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED BY THE CONTROLLER AND CEO AND MADE AVAILABLE TO THE BOARD OF DIRECTORS BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM ANNUALLY. THE FORMS ARE REVIEWED BY THE COMPLIANCE OFFICER FOR POTENTIAL CONFLICTS. ANY ACTUAL CONFLICTS ARE REVIEWED BY THE BOARD OF DIRECTORS. A PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION IS DETERMINED ON AN ANNUAL BASIS BY A COMPENSATION COMMITTEE BASED ON COMPARABILITY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGE IN COMMITTEE OVERSIGHT AUDIT FROM PRIOR YEAR FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS A FINANCE COMMITTEE SERVING AS THE AUDIT COMMITTEE. THE FINANCE COMMITTEE SELECTS THE ENGAGEMENT OF INDIVIDUAL AUDITOR AND OVERSEES THE INDIVIDUAL AUDITOR'S WORK. THERE IS NO CHANGE FROM PRIOR YEAR. NORTHERN COCHISE HOSPITAL DISTRICT 901 REX ALLEN DR WILCOX AZ 85643 TO ENSURE THE OPERATION OF THE HOSPITAL WITHIN THE DISTRICT AZ 170(C)(1) N/A N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NORTHERN COCHISE HOSPITAL DISTRICT C 1581392 ACTUAL CASH AMOUNT TRANSFERRED