2012-08-29T11:11:53-05:00 2011-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2011-01-01 480576039 Clara Barton Hospital Association Inc CLAR 6206532114 250 West 9th Street Hoisington KS 675441799 Jim Blackwell 6206532114 2012-08-23 1 Gary D Knoll P00203954 7852334226 2012-08-23 2011 2016-02-24 21:20:13Z Jim Blackwell 250 West 9th Street Hoisington KS 675441799 16463933 0 X N/A X 1946 KS Provide inpatient and outpatient services to the residents of the Hoisington,KS area. 10 9 177 13 0 0 18500 61849 15659526 16004838 95346 81422 272592 304962 16045964 16453071 0 0 0 0 8523226 8587140 0 0 64951 7487645 7622684 16010871 16209824 35093 243247 12003905 12123861 6152167 5893850 5851738 6230011 X Clara Barton Hospital Association, Inc, is dedicated to meeting the health care needs and improving the quality of life for the community we serve. We continually pursue clinical excellence in an atmosphere of caring and compassion. We are deeply committed to serving all in need within our resources. 0 0 13676854 16144173 Clara Barton Hospital Association, Inc. is a community acute care hospital, which provides inpatient and outpatient healthcare services for it's patients. 13676854 1 1 0 0 0 0 0 0 0 0 1 1 0 1 0 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 0 0 0 0 0 1 0 0 0 0 1 43 0 1 177 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Jim Blackwell 6206532114 250 West 9th Street Hoisington KS 675441799 Curt Colson 38.00 X X 85866 0 23090 Jon Radke 1.00 X X 0 0 0 Kary Miller 1.00 X X 0 0 0 Kathy Kaiser 1.00 X X 0 0 0 Troy Bailey 1.00 X X 0 0 0 Paul Woydziak 1.00 X 0 0 0 Jean Cavanaugh 1.00 X 0 0 0 Brad Tajchman 1.00 X 0 0 0 Mike Aylward 1.00 X 0 0 0 Robin Durrett DO 1.00 X 0 0 0 William C Waters 32.90 X X 30906 0 3195 James G Blackwell 33.00 X 94073 0 28247 Ann R Taylor 60.20 X 296478 0 25344 Joshua Durham 41.40 X 267468 0 24868 Nathaniel Knackstedt 34.00 X 242490 0 32604 Linda Krug 35.50 X 117179 0 19638 Celeste Meitner 35.20 X 103962 0 14705 1238422 0 171691 7 0 1 0 Docs Who Care PA 1337 South Fountain Drive Olathe KS 66061 ER Physician Coverage 345237 Allstaff Chtd 2000 Washington Great Bend KS 67530 Nursing 288647 Aramark Uniform Services 2275 Cassens Drive Fenton MO 63026 Laundry 253246 Niedens Construction Inc 195 NE 40 Road Great Bend KS 67530 Russell Clinic Construction 192346 Mobile Imaging Inc 3520 Lakin Ave Great Bend KS 67530 Sonography 190269 9 6901 33864 21084 61849 Patient service revenu 621990 16004838 16004838 16004838 79279 79279 90090 90090 31751 8855 22896 22896 22896 1150 3000 0 2007 1150 993 2143 2143 Miscellaneous 900099 139335 139335 Cafeteria 722210 42205 42205 Meals on wheels 624210 10436 10436 191976 16453071 16144173 0 247049 271899 271899 6671444 5594750 1025826 50868 133918 113026 19871 1021 1015039 872084 135216 7739 494840 399139 91928 3773 26048 26048 4750 4750 118282 118282 63028 30375 32653 698278 606780 89948 1550 162213 162213 333635 263991 69644 32980 29511 3469 221546 221546 879881 879881 113461 113461 Purchased services 2243392 2134496 108896 Pharmacy supplies 736057 736057 Medical supplies 715001 715001 Bad debts 560916 560916 713216 519301 193915 16209824 13676854 2468019 64951 172111 167448 1626534 1608969 1306259 1765385 559138 523689 169284 208392 12360294 7848415 4906056 4511879 1905898 2178544 1358625 1159555 12003905 12123861 1408257 1647331 3990871 3740784 753039 505735 6152167 5893850 X 5433441 5668498 160991 299038 257306 262475 5851738 6230011 12003905 12123861 X 243247 135026 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 408566 365735 42831 6462690 3859178 2603512 4396449 3189716 1206733 1092589 433786 658803 4511879 Mutal funds and government obligations 2178544 F 2178544 Beneficial interest in net assets of CBH Foundation 496351 Deferred financing costs 134887 Accrued Interest receivable 8894 Estimated third-party payor settlements 519423 1159555 16453071 16209824 243247 -20230 155256 135026 378273 16444881 -20230 45904 25674 16419207 33864 33864 16453071 16209824 0 16209824 0 16209824 Description of Uncertain Tax Positions Under FIN 48: Part X: The Hospital is a no-for-porfit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Sectin 501(a) of the code. Management is not aware of any uncertainties in income tax positions. Tax years ending on and before December 31, 2007, are not subject to examination by taxing authorities. Part XI, Line 8 - Other Adjustments: Temporarily restricted net assets released for acquisition of property 45,904. Temporarily restricted net assets released for acquisition of property -45,904. Temporarily restricted net assets released for operations -6,901. Change in temporarily restricted beneficial interest in Foundation 156,988. Change in permanently restricted beneficial interest in Foundation 5,169. Restricted contributions Total to Schedule D, Part XI, Line 8: 155,256. Part XII, Line 2d - Other Adjustments: Temporarily restricted net assets released for acquistion of property 45,904. Part XII, Line 4b - Other Adjustments: Government Contributions 33,864. 1 1 1 X 1 X 1 1 0 0 378314 378314 0.02420 793517 612012 181505 0.01160 1171831 612012 559819 0.03580 3005 0 3005 0.00020 21869 400 21469 0.00140 3913883 2982847 931036 0.05950 3770 3770 0.00020 3942527 2983247 959280 0.06130 5114358 3595259 1519099 0.09710 1 371631 37163 6305623 6244707 60916 X 1 1 1 1 Clara Barton Hospital

250 West 9th Street Hoisington KS 675441799

X X X X physician clinic & rural health clinic Clara Barton Hospital Association Inc 1 1 X X X X X 10 1 0 1 X X X 1 1 1 100.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 1 Russell Family Medical Care

410 N Main Street Suite C Russell KS 67665

Rural health clinic Part I, Line 7: Financial assistance at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was used to determine the cost of financial assistance provided for services not reported as subsidized health services.Unreimbursed Medicaid costs were also determined using a blend of cost-to-charge ratios for certain services and an overall cost-to-charge ratio derived from Worksheet 2 for all other services.The cost of providing subsidized health services was determined using a cost-to-charge ratio for each service.Actual costs and revenues were utilized for all other items reported on line 7. Part I, Line 7g: Subsidized health services are comprised of services that the Hospital provides despite a financial loss to the organization. These services include the operation of a 24-hour emergency room and the operation of two rural health clinics. Costs attributable to physician clinics included on line 7(g), column (c) were $2,330,390 and unreimbursed costs attributable to physician clinics included on line 7(g), column (e) were $365,525. 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 $ 560916. Part III, Line 4: 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 its accounts receivable and its historical collection experience for each type of payor.Bad debt expense at cost was determined by using the overall cost to charge ratio derived from Worksheet 2 applied to the charges deemed uncollectible during the year.Bad debt expense attributable to patients eligible under the organization's financial assistance policy were determined using an estimated 10% of total bad debts. The Hospital takes steps to assist individuals who are believed to qualify for financial assistance prior to writing accounts off as uncollectible.All non-reimbursed costs for treatment of patients in our community provides a community benefit since patients unwilling or unable to pay have received a valuable service at no cost or at a reduced cost to them. This improves the health of our community as a whole. Part III, Line 8: Medicare allowable costs were determined by using amounts from the Hospital's Medicare cost report as filed with the Medicare Administrative Contractor. The Medicare cost report apportions actual costs to the Medicare program using charges for ancillary services and patient days for nursing services. Part III, Line 9b: 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 the patient's 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. Clara Barton Hospital Association, Inc. Part V, Section B, Line 3: Input was collected from interviews with key members of the community and from a focus group with community members. Clara Barton Hospital Association, Inc. Part V, Section B, Line 5c: Clara Barton Hospital Association, Inc. held six community meetings and conducted a phone survey. Clara Barton Hospital Association, Inc. Part V, Section B, Line 15e: Clara Barton Hospital Association, Inc., is permitted to issue a medical lien for unpaid patient accounts on any future income that a patient may receive from a lawsuit. Clara Barton Hospital Association, Inc. Part V, Section B, Line 17e: Clara Barton Hospital Association, Inc., notified all uninsured patients about the Hospital's charity care program by letter. Clara Barton Hospital Association, Inc. Part V, Section B, Line 19d: Clara Barton Hospital Association, Inc. bills self-pay patients for the gross charge amount based on a set pricing structure. A discount of varying percentage is given to patients' self-pay accounts if the account balance is paid promptly and in full within the first 30, 60 and 90 days after billing. Discounts of 30%, 20% and 10% are given. Part VI, Line 2: Kansas Rural Health Works performed a community needs assessment of Barton County, Kansas along with the City of Hoisington. The community needs assessment report was issued on December 3, 2010. Through interviews of key members of the community, a focus group with community members, and a comparative analysis with documents generated from a local government research and extension office, KRHW was able to evaluate the major community needs of Clara Barton Hospital's service area. Part VI, Line 3: There is signage posted at admissions desk. Patients are referred to a financial counselor at admission if they do not have insurance. The financial counselor also works with a Medicaid helper to try and get qualified patients register for the Medicaid program. Effort is made during billing of deductible and co-payment to see if patient can qualify for charity care. Part VI, Line 4: The community being served is located in central Kansas and consists of approximately 2,800 residents. The average household income is $32,993. 15.4% of the community residents live below federal poverty level, and 4.7% of the community residents live below 50% of the federal poverty level. Neighboring hospitals include one facilities in Ellinwood and Great Bend. They are approximately 18 and 10 miles away respectively. Part VI, Line 5: The Hospital's Board of Directors is elected from the community at large. This allows independent individuals who reside in the primary service area to serve as a director. The Hospital also extends medical staff privileges to all qualified physicians in the community. Any surplus in funds is retained by the Hospital and aids in improving overall patient care and facility maintenance. X 0 0 X X X 0 0 0 0 0 0 0 0 0 Ann R Taylor 296478 0 0 0 0 0 0 0 25344 0 321822 0 0 0 Joshua Durham 267468 0 0 0 0 0 0 0 24868 0 292336 0 0 0 Nathaniel Knackstedt 242490 0 0 0 0 0 7260 0 25344 0 275094 0 0 0 Hoisington Public Building Commission Hoisington Kansas 486012386 000434661 2006-03-23 5019230 Health Care Facilities Refunding Revenue Bonds 0 0 0 1220000 2006 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 6 Members of Clara Barton Hospital Foundation, Inc. are automatically members of Clara Barton Hospital Association, Inc. Form 990, Part VI, Section A, line 7a Members of Clara Barton Hospital Association, Inc., elect members of the governing body Form 990, Part VI, Section B, line 11 Form 990 provided to governing body and reviewed prior to filing. Form 990, Part VI, Section B, line 12c A conflict of interest disclosure form is provided to each Board Member and is reviewed annually. Form 990, Part VI, Section B, line 15 The organization uses the KHA Salary Survey as a guide for executive compensation and the Board of Directors reviews salaries. 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 written request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -20,230. Temporarily restricted net assets released for acquisition of property 45,904. Temporarily restricted net assets released for acquisition of property -45,904. Temporarily restricted net assets released for operations -6,901. Change in temporarily restricted beneficial interest in Foundation 156,988. Change in permanently restricted beneficial interest in Foundation 5,169. Restricted contributions Total to Form 990, Part XI, Line 5: 135,026. Financial Statements and Reporting 990, Part XII, Page 11, Line 2c Clara Barton Hospital Association's Finance Committee is responsible for each of these functions. Clara Barton Hospital Foundation Inc PO Box 25 Hoisington KS 67544 481077460 Provide support to the hospital. KS 501(c)(3) 170(b)(1) 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Clara Barton Hospital Foundation Inc C 64103 Clara Barton Hospital Foundation Inc B 54856