2011-05-16T09:42:03-05:00 2010-06-30 CHMS PC 741 3rd Ave S Glasgow MT 59230 990 2009-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVE SW SIDNEY MT 59270 TINA MONTGOMERY 4064882100 2011-05-20 1 Richard A Wiens CPA 4062289391 2009 2016-02-24 21:20:13Z TINA MONTGOMERY 216 14TH AVE SW SIDNEY MT 59270 40731224 0 X www.sidneyhealth.org X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THIER HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 10 8 643 150 5487494 -2148040 586372 157967 36988993 39217237 108225 277911 81184 61626 37764774 39714741 0 0 20541382 20508024 0 232423 19067388 20035933 39608770 40543957 -1843996 -829216 61507011 62129772 31080103 32532080 30426908 29597692 0 0 29424196 33729743 REVENUE AND EXPENSES DIRECTLY RELATED TO PATIENT CARE. 29424196 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 31 0 643 1 1 1 0 0 0 0 0 0 10 8 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X TINA MONTGOMERY 4064882117 2816 4TH STREET NW SIDNEY MT 59270 PAM BURMAN 1.00 X 0 0 0 MIKE MOHL 1.00 X 0 0 0 TAMI CHRISTENSEN 2.00 X 0 0 0 RANDY JOHNSON 1.00 X 0 0 0 LAURA SCHIEBER 1.00 X 0 0 0 Janice Norby 1.00 X 0 0 0 Gale Frank 1.00 X 0 0 0 STEVE SING 1.00 X 0 0 0 Rajohn Karanjai MD 40.00 X 0 0 0 CARLOS TREVINOS 40.00 X X 278986 0 19230 RICK HARALDSON 40.00 X X 187974 0 15929 TINA MONTGOMERY 40.00 X 99999 0 18960 Lotfi Ben-youssef 40.00 X 457272 0 9887 C Scordalakes 40.00 X 368484 0 25703 Brad Struupp 40.00 X 306013 0 22499 Bard Lundemo 40.00 X 298460 0 24615 1997188 0 136823 6 0 1 0 Brett Bennion MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 392244 EDWARD L PIERCE MD PC 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 349408 PETE COUNCIL MD 214 14TH AVE SW SUITE 104 SIDNEY MT 59270 PHYSICIAN SERVICES 239053 SODEXO OPERATIONS LLC 4880 PAYSPHERE CIRCLE PITTSBURG PA 15262 Food Services 214705 RAJOHN KARANJAI MD PC 214 14TH AVE SW SUITE 110 SIDNEY MT 59270 PHYSICIAN SERVICES 157170 6 157967 157967 PatIENT REVENUE 900099 33729743 33729743 CLINIC PHARMACY 446110 3683842 3683842 PHYSICIAN OFFICES 621110 1346764 1346764 MONDAK PHARMACY 446110 456888 456888 39217237 264093 264093 60493 60493 60493 60493 1030301 1016483 13818 13818 13818 1133 1133 1133 39714741 34069280 5487494 0 16547790 10528359 5888123 131308 348585 290216 55324 3045 2515869 2209698 283564 22607 1095780 941123 145981 8676 755842 493313 234556 27973 8102 8102 53723 53723 110704 110704 2154944 1790555 364389 135850 9976 119714 6160 7899167 7493246 403005 2916 1904564 1184068 712682 7814 181074 125042 51832 4200 90017 59317 27238 3462 1326378 1326378 2697522 2697522 511309 495711 15598 BAD DEBT EXPENSE 921434 921434 TAXES 431682 416146 14577 959 RECRUITING 77356 54040 10677 12639 DONATIONS 6220 2465 3755 770045 633399 135982 664 40543957 29424196 10887338 232423 11218886 9088068 5530235 6675912 3095307 2995580 1260955 1298473 643267 717011 56944977 27976815 22788454 28968162 3097720 3380231 4372888 1294927 5509535 5935148 3989764 1776260 61507011 62129772 3404742 3428190 9515000 9425000 16375000 17222219 1785361 2456671 31080103 32532080 X 29713497 29597692 713411 0 30426908 29597692 61507011 62129772 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 32500 0 0 0 0 0 0 0 0 0 Part I-A, Line 1: Organizations Direct and Indirect Political Campaign Activities: HIRED A LOBBYIST TO ENGAGE IN POLITICAL ACTIVITY. 198261 198261 36511638 15336856 21174782 18499247 12639959 5859288 1735831 1735831 28968162 FUNDED DEPRECIATION 5935148 F 5935148 INTEREST RATE SWAP LIABILITY 2413419 Medicare/Medicaid, Est. Payable 43252 2456671 39714741 40543957 1 1 1 X 1 X 1 1 1 0 90553 90553 0.00230 4581605 5554709 -973104 0.00000 4672158 5554709 -882551 0.00230 4672158 5554709 -882551 0.00230 1 707769 100920 6360533 4885627 1474906 X 1 1 SIDNEY HEALTH CENTER

216 14TH AVENUE SW SIDNEY MT 59270

X X X X Part I, Line 3c: Individual Applying for Charity care must provide pay stubs, thier most recent tax return, forms approving or denying eligibility for medicaid and or state or county funded medical assistance, forms approving or denying unemployment compensation and current bank statements. The items listed above will be used to determine family income. Family income and family size are then used to determine what the poverty threshold is for the applicant and to determine if free or discounted care will be approved. Part I, Line 7f: Accounts Receivable are carried net of an estimate for uncollectibles and allowances. Accounts which are not considered collectible are written off against the allowance account. Allowances for uncollectible accounts are set based on historical loss rates applied to aged accounts receivable. Bad debts are classified as an operating expense. Part III, Line 4: Accounts Receivable are carried net of an estimate for uncollectibles and allowances. Accounts which are not considered collectible are written off against the allowance account. Allowances for uncollectible accounts are set based on historical loss rates applied to aged accounts receivable. Bad debts are classified as an operating expense. Part III, Line 8: THE COST TO CHARGE RATIO IS USED TO DETERMINE COMMUNITY BENEFIT. THIS IS DONE BY APPLYING THE RATIO TO THE TOTAL MEDICARE REVENUE. THE SHORTFALL OCCURRS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. Part III, Line 9b: A PATIENT ACCOUNTS REP MAINTAINS A CURRENT AGING REPORT MONTHLY. AN ACCOUNT IS CONSIDERED DELINQUENT IF IT IS NOT PAID WITHIN THIRTY DAYS OF THE MAILING OF THE FIRST STATEMENT. IF PAYMENT IS NOT RECEIVED IN THE FOLLOWING BILLING CYCLE, THE PATIENT IS IS ISSUED A "PAYMENT MISSED" STICKER,ENCOURAGING PATIENTS TO MAKE PAYMENT. ALL BILLS ARE CONSIDERED PAST DUE IF NOT PAID BY THE THIRD BILLING CYCLE. A FINAL NOTICE WILL BE ISSUED IF PAYMENT IS NOT RECEIVED BY THE FOURTH BILLING CYCLE. IF PAYMENT IS NOT MADE WITHIN 5 BUSINESS DAYS AFTER THE FOURTH BILLING CYCLE THE PATIENT'S ACCOUNT WILL BE SENT TO COLLECTION. 0 0 0 0 0 0 0 0 0 CARLOS TREVINOS 278986 0 0 0 0 0 3510 0 15720 0 298216 0 236924 0 RICK HARALDSON 187974 0 0 0 0 0 209 0 15720 0 203903 0 183634 0 Lotfi Ben-youssef 457272 0 0 0 0 0 9887 0 0 0 467159 0 0 0 C Scordalakes 368484 0 0 0 0 0 9983 0 15720 0 394187 0 367730 0 Brad Struupp 306013 0 0 0 0 0 6779 0 15720 0 328512 0 286751 0 Bard Lundemo 298460 0 0 0 0 0 8895 0 15720 0 323075 0 290179 0 Richland County 2008-07-03 9685000 Contruction 0 0 3829796 967947 670457 2710046 2010 0 1 0 0 Form 990, Part VI, Section B, line 11 A COPY OF THE 990 WAS GIVEN TO THE CFO AND MADE AVAILABLE TO THE BOARD FOR APPROVAL. Form 990, Part VI, Section B, line 12c A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO THE BOARD ANNUALLY AND IS REQUIRED TO BE FILLED OUT BY EACH MEMBER. Form 990, Part VI, Section B, line 15 THE BOARD REVIEWS THE MONTANA HOSPITAL COMPENSATION SALARIES FOR COMPARABLE HOSPITALS ANNUALLY AND COMPARE TO THE SALARIES BEING PAID BY THE FACILITY. Form 990, Part VI, Section C, line 19 POLICIES ARE KEPT AT THE HOSPITAL AND ARE AVAILABLE UPON REQUEST. Lone Tree Senior Living 216 14th Avenue SW Sidney MT 59270 810518821 Operation of an Assisted Living MT 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Lone Tree Senior Living K 74722 Lone Tree Senior Living A 141740 Lone Tree Senior Living D 2963502 Health Net LLC 11 South 7th Suite 241 Miles City MT 59301 810506005 Data Processing MT 1 218117 0 0