2011-05-12T13:09:19-05:00 2010-06-30 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2009-07-01 440629397 Carroll County Memorial Hospital CARR 6605421695 1502 N Jefferson St Carrollton MO 64633 Jerry Dover 6605421695 2011-05-05 1 Gary D Knoll 7852334226 2011-05-05 2009 2016-02-24 21:20:13Z Jerry Dover 1502 N Jefferson St Carrollton MO 64633 12997843 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 9 201 12 0 0 42751 8960 11606395 12629286 292424 224828 108223 121255 12049793 12984329 0 0 6428822 6870281 0 0 5242593 5387191 11671415 12257472 378378 726857 21509515 22779169 1042509 1049342 20467006 21729827 To improve the health of the community by assuring excellent medical care to our citizens. 0 0 8492909 12629286 Acute care hospital organized to provide inpatient and outpatient care to area residents regardless of their ability to pay. 8492909 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 17 0 0 201 1 0 0 0 0 0 0 0 0 0 0 0 0 9 9 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 1 0 0 MO X X X Jeff Tindle CFO 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 167105 0 17414 Jeffrey Tindle 40.00 X 114270 0 13427 Waclaw A Dymek 40.00 X 140881 0 16105 Julie Marvin 40.00 X 141856 0 9075 Richard Smith 40.00 X 180686 0 24000 Tim Reid 40.00 X 55994 0 7200 744798 0 80021 5 0 1 0 Cerner Corporation 2800 Rock Creek Parkway Kansas City MO 64117 Computer Systems 250088 Clinishare Inc 19600 E 39th Street Independence MO 64057 Nuclear Medicine 246661 Richard L Smith MD 20644 HWY Z Chillicothe MO 64601 ER Physician Coverage 155445 Emcare Physician Services 7032 Collection Center Dr Chicago IL 60693 ER Physician Coverage 141849 HSMC Technology Services Inc 3550 NE Ralph Powell Rd Lees Summit MO 64184 IT Service 107159 6 8960 8960 Net Patient service re 621990 12629286 12629286 12629286 238342 238342 57600 57600 57600 57600 13514 -13514 -13514 -13514 Other income 900099 44089 44089 Vending 900099 10611 10611 Medical record fees 621990 4819 4819 4136 4136 63655 12984329 12629286 0 346083 308353 308353 5156855 4333182 823673 258975 224200 34775 768111 619355 148756 377987 301976 76011 21855 596 21259 717409 580966 136443 19255 12929 6326 999483 849343 150140 96049 96049 448821 137501 311320 555 555 1110176 1110176 108617 108617 Collection fees and bad 527131 527131 Professional Fees 470877 440916 29961 Medicaid FRA Tax 319811 319811 Equipment rental and ma 315395 181585 133810 Dietary supplies 122022 122022 109735 65158 44577 12257472 8492909 3764563 0 6277030 7533874 1522126 1596950 116404 117529 28577 101789 18338032 7771720 11290918 10566312 1865348 2306776 409112 555939 21509515 22779169 1017808 1026725 24701 22617 1042509 1049342 X 20467006 21729827 20467006 21729827 21509515 22779169 X 0 1 0 X 0 X 18338032 7771720 10566312 10566312 Equity securities 1369120 F Corporate bonds 937656 F 2306776 Property and equipment purchases payable 22617 22617 12984329 12257472 726857 535964 535964 1262821 13520293 535964 535964 12984329 0 12984329 12257472 0 12257472 0 12257472 Part X: Description of Uncertain Tax Positions Under FIN 48: N/A 1 1 1 X 1 X 1 0 0 1 1 134654 84138 50516 0.00430 1729711 1328331 401380 0.03420 1864365 1412469 451896 0.03850 2210 2210 0.00020 4000 4000 0.00030 3623025 2164886 1458139 0.12430 504 504 0.00000 3629739 2164886 1464853 0.12480 5494104 3577355 1916749 0.16330 1 279432 184807 4805225 4757649 47576 X 1 1 Carroll County Memorial Hospital

1502 North Jefferson Carrollton MO 64633

X X X X Physician clinics 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 Hospitals 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, 2010. 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. 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 Marshall, Lexington, and Richmond. The distance between Carroll County Memorial Hospital and these facilities is approximately 20, 25, and 27 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 local community. 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 167105 0 0 0 0 0 13094 0 4320 0 184519 0 81193 0 Waclaw A Dymek 140881 0 0 0 0 0 11785 0 4320 0 156986 0 71382 0 Julie Marvin 141856 0 0 0 0 0 9075 0 0 0 150931 0 56376 0 Richard Smith 180686 0 0 0 0 0 14400 0 9600 0 204686 0 9002 0 Dr Alex Dymek Operating X 20000 20000 0 1 1 Dr Alex Dymek Operating X 40000 40000 0 1 1 Andrew Horine Medical School X 40000 40000 0 1 1 100000 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 15a The organization uses comparability data to determine the compensation of the chief executive officer, with final approval by the board of directors. Form 990, Part VI, Section C, line 19 The organization makes its governing documents and audited financial statements available to the public upon written request.