2011-10-27T12:56:43-05:00 2010-12-31 EIDE BAILLY LLP 1601 NW Expressway Oklahoma City OK 73118 990 2010-01-01 731279909 Okmulgee Memorial Hospital Inc OKMU 9187564233 1401 Morris Drive Okmulgee OK 74447 Paul Ervin 9187564233 2011-10-12 1 Carolyn Levings 4054783334 2011-10-12 2010 2016-03-07 17:11:31Z Paul Ervin 1401 Morris Drive Okmulgee OK 74447 20444985 0 X http://www.okmulgeehospital.com X 1967 OK HEALTH CARE SERVICES 10 10 324 85 0 0 0 200529 19271373 20243573 1482 883 422478 0 19695333 20444985 0 0 0 0 10022031 10494101 0 0 0 10356110 10957572 20378141 21451673 -682808 -1006688 5172011 5373192 3253482 4461351 1918529 911841 X Okmulgee Memorial Hospital's mission is to put our patients and customers first and to provide quality health care in an efficient manner. 1 0 17513828 20243573 Okmulgee Hospital is a 66 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 $255,933 of charity care in 2010. 17513828 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 18 0 1 324 1 0 0 0 0 0 0 0 0 X 10 10 1 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 OK X Paul Ervin 9187583102 1401 Morris Drive Okmulgee OK 74447 John Fidler 1.00 X X 0 0 0 Nevyle Cable 1.00 X X 0 0 0 Barbara Osborn 1.00 X X 0 0 0 Greg Marriott 1.00 X X 0 0 0 Tracy Sanford 1.00 X 0 0 0 Timothy Sandford 1.00 X 0 0 0 Linda Janzen 1.00 X 0 0 0 Walter McGown 1.00 X 0 0 0 Jason Winters 1.00 X 0 0 0 Stanley White MD 1.00 X 0 0 0 John Crawford 40.00 X 128350 0 2871 Rex Jones-Mgmt Company 40.00 X 159000 0 58880 Jason Bruce MD 40.00 X 293251 0 18463 Benjamin Kamp DO 40.00 X 171364 0 4071 751965 0 84285 4 0 1 0 Cardinal Health PO Box 847384 Dallas TX 75284 Supplies/Med & Pharmacy 675061 Horizon Health PO Box 840839 Dallas TX 75284 Mental Health 486129 Quorum Health Resources 105 Continental Pl Brentwood TN 37027 ER Physicians 417655 Total Medical PO Box 26243 Oklahoma City OK 73126 Hospital Mgmt 340359 Okmulgee ER Services PO Box 1038 Okmulgee OK 74447 Contract Nursing 255292 18 200529 200529 200529 Net Patient Serv. Rev. 624100 20062123 20062123 Dietary 900099 87960 87960 Maint. & Janitorial 900099 48161 48161 Miscellaneous Revenue 900099 35344 35344 Security Services 900099 9985 9985 20243573 883 883 20444985 20243573 0 883 677110 315980 361130 7206884 5824260 1382624 99044 74692 24352 1881603 1418982 462621 629460 474697 154763 24445 24445 62540 62540 2378258 1982449 395809 86865 60000 26865 3349581 2537684 811897 18546 6689 11857 2331 1461 870 68921 46798 22123 124724 124724 624599 468449 156150 246774 209830 36944 Bad debt expense 3907582 3907582 Dues & Subscriptions 62406 59551 2855 21451673 17513828 3937845 0 22892 14718 2243759 2103925 829016 787769 83692 233876 12502961 10270057 1992652 2232904 5172011 5373192 1619256 2360125 1634226 2020985 0 80241 3253482 4461351 X 1918529 911841 1918529 911841 5172011 5373192 -1006688 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 22716 22716 5367013 4738299 628714 102260 102260 0 7010972 5429498 1581474 2232904 Estimated Third Party Settlements 80241 80241 20444985 21451673 -1006688 0 -1006688 20244456 0 20244456 200529 200529 20444985 21451673 0 21451673 0 21451673 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, 2010 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 1 1 X 1 X 1 X 1 1 0 0 105462 105462 0.00600 3511376 2544844 966532 0.05510 3616838 2544844 1071994 0.06110 60800 60800 0.00350 60800 60800 0.00350 3677638 2544844 1132794 0.06460 1 1615779 9840 8993621 8766519 227102 X 1 0 1 1 Okmulgee Memorial Hospital

1401 Morris Drive Okmulgee OK 74447

X X X Psych-16 Beds Okmulgee Memorial Hospital Inc 1 2 Home Health Agency

1401 Morris Drive Okmulgee OK 744476419

In-Home Care Service Benjamin A Kamp DO

1201 S Belmont Ste 207 Okmulgee OK 744476419

Clinic Part I, Line 7: Charity care was converted to cost using a cost-to charge ratio calculated from Worksheet 2.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 the denominator of the calculation was $3,907,582. Part III, Line 4: Bad debt expense was converted to cost using the cost-to-charge ratio derived from Worksheet 2.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 best 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: The costs associated with Medicare were taken from the Medicare Cost Report. 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. 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 asssessment 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 Medicare. If the patient is not eligible for Medicare, 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 6: 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. X X 0 0 0 0 0 0 0 0 0 Rex Jones-Mgmt Company 159000 0 0 0 0 0 0 0 58880 0 217880 0 0 0 Jason Bruce MD 293251 0 0 0 0 0 9147 0 9316 0 311714 0 0 0 Benjamin Kamp DO 171364 0 0 0 0 0 0 0 4071 0 175435 0 0 0 X VITEK MACHINE 1 57700 X BOILERS 1 142829 0 0 0 Method for Determining Number of Contributors: Part I, Column (b): The machine and boilers were donated from the Okmulgee Medical Foundation, Inc. to the Hospital. Various contributions were made to the Foundation and the equipment was donated to the Hospital. New Program Services Form 990, Part III, line 2 In 2010 we expanded the clinic program including prenatal and cardiology. We also employed a physician/surgeon. Form 990, Part VI, Section A, line 2 Tracy & Timothy Sanford (Trustees) - family relationship Form 990, Part VI, Section A, line 3 Management duties include planning and executing financial operations. Quorem Health Resources manages the hospital. Form 990, Part VI, Section A, line 8b The organization does not have a committee with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The 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 12c We 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 15 The 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 19 The organization makes its governing documents, conflict of interest policy, and financial statemsnts available to the public upon request. Okmulgee Medical Foundation Inc PO Box 1038 Okmulgee OK 74447 730766656 Office building and manages tax deductible contributions OK 501(c)(3) 509(a)(1) 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 Okmulgee Medical Foundation I 56000 FMV Okmulgee Medical Foundation R 200529 FMV