2011-11-14T15:43:47-05:00 2010-12-31 BKD LLP 111 South Tejon Suite 800 Colorado Springs CO 809039848 990 2010-01-01 841262971 Poudre Valley Health Care Inc POUD 9702377000 2315 E Harmony Road Fort Collins CO 80528 STEPHANIE DOUGHTY 2011-09-06 true Rita F Worster CPA 7194714290 2010 2016-03-07 17:11:31Z Rulon Stacey 2315 E HARMONY RD SUITE 200 Fort Collins CO 80528 606197592 false X www.pvhs.org X 1994 CO POUDRE VALLEY HEALTH SYSTEM IS AN INTEGRATED, INDEPENDENT, NON-PROFIT ORGANIZATION, PROVIDING INNOVATIVE, COMPREHENSIVE CARE OF HIGHEST QUALITY & EXCEEDING EXPECTATIONS OF THE COMMUNITIES WE SERVE. 11 7 5733 689 11131800 2237147 722152 8098366 362056421 423726041 9078274 8470934 7897938 8904167 379754785 449199508 1230471 1482109 0 0 184305989 218684389 0 0 0 152607756 190771747 338144216 410938245 41610569 38261263 668057923 727783197 215471203 235600988 452586720 492182209 X THE MISSION OF POUDRE VALLEY HEALTH SYSTEM IS TO BE AN INTEGRATED, INDEPENDENT, NON-PROFIT ORGANIZATION PROVIDING INNOVATIVE, COMPREHENSIVE CARE OF THE HIGHEST QUALITY AND EXCEEDING EXPECTATIONS OF THE COMMUNITIES WE SERVE. true false 321024454 1482109 381426876 Poudre Valley Health Care Inc (PVHC) provides tertiary, acute, inpatent, outpatient as well as emergency care. PVHC services communities in Northern Colorado, Southwestern Nebraska and Southeastern Wyoming. During 2010 PVHC recorded 58,924 patient days; 15,519 discharges; 471,496 outpatient visits; 43,984 emergency visits; 3,136 births; 5,988 inpatient surgeries; and 3,477 outpatient surgeries. 46716755 37107962 Poudre Valley Medical Group, LLC was created to integrate Poudre Valley Health System with physician practices, at year end 2010 PVMG, LLC was comprised of 105 employed physicians representing 21 specialties at 17 medical clinics in 22 communities in Colorado, Nebraska and Wyoming. 367741209 true true false true false false false false false true false true false true true false true false false false false false false false false true false true false true true false false false false false true false false true true true false false false true true true true false false true 522 0 true 5733 true true true false false false false false false false false false X 11 7 false false false false false false false true true false false true true true true true true true true true true X THE ORGANIZATION 9702377000 2315 E HARMONY RD SUITE 200 Fort Collins CO 80528 X STU VANMEVEREN 2.0 X X 0 0 0 CHRIS OSBORN 2.0 X X 307 0 0 CHRISTINE CHIN 2.0 X 0 0 0 MIKE DELLENBACH 2.0 X 0 0 0 GARY LUDWIN 2.0 X 0 0 0 THAINE MICHIE 2.0 X 0 0 0 TODD SORENSEN MD 2.0 X 313 0 0 LAURIE STEELE 2.0 X 557 0 0 DAN STROH 2.0 X 813 0 0 JOE HENDRICKSON 2.0 X 0 0 0 RULON STACEY 40.0 X X 1649479 0 834648 TODD WHITSITT MD 40.0 X 263103 0 8650 CHRIS KNEELAND 2.0 X 0 0 0 LEE THIELEN 2.0 X 0 0 0 STEPHANIE DOUGHTY 40.0 X 465217 0 229676 RUSS BRANZELL 40.0 X 344623 0 145984 PAMELA BROCK 40.0 X 538577 0 113969 DIANE GROSS 40.0 X 451018 0 70369 CRAIG LUZINSKI 40.0 X 265478 0 105106 WILLIAM NEFF MD 40.0 X 390885 0 156656 PATTI OAKES 40.0 X 220086 0 96934 DAN ROBINSON 40.0 X 231992 0 144738 KEVIN UNGER 40.0 X 386813 0 200493 BARB YOSSES 10.0 X 294857 0 157182 AUSTIN BAILEY MD 40.0 X 241360 0 44282 MARY BLATTNER MD 40.0 X 295414 0 7081 JOSEPH GOTTFRIED MD 40.0 X 240391 0 40148 GERALD MCINTOSH MD 40.0 X 325623 0 21820 JOHN NAGEL MD 40.0 X 250280 0 31586 6857186 0 2409322 213 false true false NORTHERN COLORADO PULMONARY CONSULT 2121 E HARMONY RD SUITE 300 FT COLLINS CO 80528 MEDICAL 1875645 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 554809146 MEDICAL 1628044 FAEGRE BENSON LLP 1700 LINCOLN STREET DENVER CO 80203 LEGAL 1340299 HARMONY ADDICTION HEALTH 2121 East Harmony Rd Ste 310 FORT COLLINS CO 80528 MEDICAL 1279558 NORTHERN COLORADO HOSPITALISTS 2121 East Harmony Rd Ste 300 FORT COLLINS CO 80528 MEDICAL 990759 52 7463218 515038 120110 360880 8098366 NET PATIENT SERVICE REVENUE 900099 386748641 386748641 PROVIDER FEE INCOME 621400 28137276 28137276 DIETARY SERVICES INCOME 900099 1893810 1893810 LAB UBI 621500 2408112 2408112 JOINT VENTURE 621400 2843179 2481630 361549 1695023 1167291 527732 423726041 7557806 7557806 554478 554478 0 6055003 457025 2791993 457025 3263010 3263010 2869112 393898 153580616 13446 153139669 95743 440947 -82297 358650 358650 0 0 730955 513654 217301 31459 185842 REIMBURSEMENT - NON OPERATING DEPTS 621400 4731940 4731940 SERVICES PROVIDED TO OUTSIDE ENTITIES 621400 147013 147013 INCOME TAX REFUND 621400 490020 490020 54883 54883 5423856 449199508 418534838 11131800 11434504 1482109 1482109 0 0 0 6328848 755314 5573534 83352 83352 165317723 156598435 8719288 7847956 6470586 1377370 26493878 22362009 4131869 12612632 10645621 1967011 0 2167006 62264 2104742 139903 139903 17607 17607 0 388774 388774 26345927 23556859 2789068 1891410 233332 1658078 59670624 58286893 1383731 7457504 6102329 1355175 0 11636390 8827422 2808968 942761 558560 384201 0 797364 594186 203178 8820433 8820433 0 21347607 19081663 2265944 3057193 2772533 284660 BAD DEBT 8196637 8196637 REPAIRS AND MAINTENANCE 7664822 6851239 813583 DIETARY, HOUSEKEEPING, LINEN 3719157 3509416 209741 UBI ESTIMATES PAID 883000 883000 PROVIDER FEE EXPENSE 21324626 21324626 4303002 565391 3737611 0 410938245 367741209 43197036 0 3817574 3595327 29828083 48816414 47497316 78566431 1497673 2302454 1345181 1743834 5119132 6175678 2891963 2931636 474303676 240094234 196524722 234209442 313941694 272009524 3010917 3011040 43704756 46464951 18878912 27956466 668057923 727783197 43767656 59860633 131359990 131351513 7940561 25144046 4094743 5244455 28308253 14000341 215471203 235600988 X 452586720 492182209 452586720 492182209 668057923 727783197 X 38261263 1334226 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false true 17607 false false 17607 false Direct Contact with Legislators, staff, Gov't officials Form 990, Sch. C, Part II-B, Line 1g Poudre Valley Hospital pays annual membership dues to CHA and AHA. A percentage of the annual dues are attributable to lobbying. The amount shown on this line is that percentage. 37794004 37794004 176328273 83665639 92662634 93081265 45017776 48063489 166820260 111410819 55409441 279874 279874 234209442 JOINT VENTURES 46464951 F 46464951 0 OTHER ACCRUED LIABILITIES 8951660 CASH OVERDRAFTS 5048681 14000341 449199508 410938245 38261263 2125305 -791079 1334226 39595489 444252776 2125305 1408216 3533521 440719255 8480253 8480253 449199508 404657283 5239062 5239062 399418221 11520024 11520024 410938245 FIN 48 DISCLOSURE SCH D PART X FIN 48 At December 31, 2010, all entities included in PVHC's consolidation are exempt from taxation under Section 501(c)(3) of the Internal Revenue Code except for Lakota Lake, LLC, PVHS/Timberline, LLC, Heron Lake, LLC, Poudre Valley Medical Group, LLC and Innovations Enterprises, Inc, including wholly-owned subsidary. Lakota Lake, LLC, PVHS/Timberline, LLC, Heron Lake, LLC, and Poudre Valley Medical Group, LLC act as tax flow-through entities to PVHC, which, as noted, is tax-exempt under Section 501(c)(3) of the Internal Revenue Code. Innovation Enterprises, Inc. is taxed on its net profit under Subsection C of the Internal Revenue Code and includes their wholly-owned LLC as a tax flow-through entity. Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. OTHER RECONCILING DIFFERENCE SCH D PART XI LINE 8 SUPPORT INTEREST RATE SWAP ADJUSTMENT ON AFS: (1,497,933) EXTRAORDINARY ITEM ADJUSTMENT ON AFS: (285,233) CONTRIBUTION FROM PV FOUNDATION NOT ON AFS: (273,750) EXCESS AUXILLARY INCOME NOT ON AFS: (181,478) AUXILLARY COGS ON AFS: (133,730) EXCESS AUXILLARY GRANTS PAID NOT ON AFS: 175,000 OTHER CHANGES ON AFS: 10,309 BOOK/TAX TIMING DIFFERENCES ON JOINT VENTURES 1,395,736 TOTAL PART XI LINE 8 AMOUNT: (791,079) OTHER RECONCILING DIFFERENCE SCH D PART XII LINE 2D SUPPORT OTHER CHANGES IN NET ASSETS: 12,480 BOOK/TAX TIMING DIFFERENCES ON JOINT VENTURES 1,395,736 TOTAL PART XII LINE 2D AMOUNT: 1,408,216 OTHER RECONCILING DIFFERENCE SCH D PART XII LINE 4B SUPPORT NET RENTAL LOSS IN EXPENSE ON AFS: (2,857,777) NON OPER RENTAL INCOME IN EXPENSE ON AFS: (1,080,940) TTT, ONCOLOGY SHOP COGS IN AFS EXPENSE: (379,924) LOSS ON SALE OF ASSETS IN EXPENSE ON AFS: (82,297) MCR PHYSICIAN NETWORK CONTRIBUTION IN AFS EXPENSE: 7,002,108 NON-OPER REIMBURSEMENTS IN EXPENSE ON AFS: 4,731,940 INCOME TAX REFUND IN EXPENSE ON AFS: 490,020 CONTRIBUTION FROM PV FDN. NOT IN AFS REV: 273,750 AUXILLARY INCOME NOT INCLUDED IN AFS INCOME: 181,478 SVCS PROVIDED TO O/S ENTITIES IN EXP ON AFS: 147,013 VARIOUS UBI INCOME NOT IN AFS INCOME: 54,882 TOTAL PART XII LINE 4B AMOUNT: 8,480,253 OTHER RECONCILING DIFFERENCE SCH D PART XIII LINE 2D SUPPORT NET RENTAL INCOME IN EXPENSE ON AFS: 2,857,777 IMPACT OF INTERST RATE SWAP ON AFS: 1,497,933 COST OF GOODS SOLD IN EXPENSE ON AFS: 513,654 IMPACT OF EXTRAORDINARY ITEM ON AFS: 285,233 LOSS ON SALE OF ASSETS IN EXPENSE ON AFS: 82,297 TIMING DIFFERENCE ON FDN/PVH CONTRIBUTIONS: 2,168 TOTAL PART XIII LINE 2D AMOUNT: 5,239,062 OTHER RECONCILING DIFFERENCE SCH D PART XIII LINE 4B SUPPORT MCR PHYSICIAN NETWORK ALLOCATION ON AFS: 7,002,108 NON-OPERATING REIMBURSEMENTS ON AFS: 4,731,940 INCOME TAX REFUND REDUCING EXPENSE ON AFS: 490,020 SERVICES PROVIDED TO O/S ENTITIES ON AFS: 147,013 VARIOUS UBI INCOME IN EXPENSE ON AFS: 54,883 NON OPER RENTAL INCOME IN EXPENSE ON 990: (1,080,940) AUXILIARY GRANTS NOT ON AFS: 175,000 TOTAL PART XIII LINE 4B AMOUNT: 11,520,024 true true X true X true X true true false true true 2475983 2475983 0.00710 35713542 18808933 16904609 0.04820 44449142 38306130 6143012 0.01750 82638667 57115063 25523604 0.07280 4456938 552715 3904223 0.01110 4314327 881103 3433224 0.00980 37159809 11091475 26068334 0.07430 849258 20752 828506 0.00240 921759 921759 0.00260 47702091 12546045 35156046 0.10020 130340758 69661108 60679650 0.17300 2010 2010 79548 79548 0.00020 341349 341349 0.00100 11556 11556 83840 20732 63108 0.00020 25341 25341 0.00010 700 700 270052 270052 0.00080 814396 20732 793664 0.00230 true 3387258 0 97373997 114717510 -17343513 X true true Harmony Surgery Ctr Ambulatory Surgery 0.50000 0.00000 0.50000 Peak Surgery Mngt Management Services 0.10000 0.00000 0.10000 Harmony Image Ctr Medical Imaging 0.46000 0.00000 0.46000 Srg Ctr Fort Collins Ambulatory Surgery 0.26000 0.00000 0.45000 Gateway Medical Svcs Real Estate/Med Equip 0.50000 0.00000 0.50000 Eye Laser Ctr NO CO Laser Surgery 0.50000 0.00000 0.50000 VEIN & LASER CTR NC LASER SURGERY 0.33000 0.00000 0.65000 1 1 Poudre Valley Hospital

1024 S Lemay Ft Collins CO 80524

X X X X X Pharmacy Lab Cardiovascular Poudre Valley Hospital 1 42 HARMONY CAMPUS AMBULATORY CARE CENTER

2127 E Harmony Rd FORT COLLINS CO 80528

SURGERY CENTER, DIAGNOSTIC CTR IMAGING, URGENT CARE Harmony Campus MOB

2121 E Harmony Rd Fort Collins CO 80528

Physician Offices, Oncology, Greeley Medical Clinic

1900 16th Street Greeley CO 80631

Physician Offices Mountain Crest Behavioral Health

4601 Corbett Dr Fort Collins CO 80528

Behavorial Health Greeley OncologyRheumatology

1800 15th Street Greeley CO 80631

Physician Office Redstone

2315 E Harmony Rd Fort Collins CO 80528

Outpaitent Lab, Physician Offi MCR North MOB

2500 Rocky Mtn Ave Loveland CO 80538

Physician offices Peakview Medical Center

5881 W 16th Street Greeley CO 80634

Physician offices Centre Ave Health and Rehab-JV

915 Centre Ave Fort Collins CO 80526

Rehab Surgery Center of Ft Collins-JV

1100 E Prospect Rd Fort Collins CO 80524

Surgery Center Westbridge

1107 S Lemay Fort Collins CO 80524

Physician offices, medical spa MCR South MOB

2500 Rocky Mtn Ave Loveland CO 80538

Physician offices BLOOD DRAW Pennock Place

1025 Pennock Place Fort Collins CO 80524

Physician offices, blood bank Prospect Medical Plaza

1106 E Prospect Suite 100 Fort Collins CO 80524

Physician offices, outpaitent Loveland OncologyHematology

2975 Ginnala Drive Suite 120 Loveland CO 80538

Oncology Express Lab

1020 Doctors Lane Fort Collins CO 80524

Lab Snow Mesa

4674 Snow Mesa Drive Fort Collins CO 80528

Physician Offices Windsor Medical Center

1455 Main Street Windsor CO 80550

Physician Offices Timerline Medical

131 Stanley Dr Estes Park CO 80517

Physician Offices Columbine Poudre Homecare-JV

915 Centre Ave Fort Collins CO 80526

Home healthcare Children's Therapy

1500 S Lemay Fort Collins CO 80526

Therapy West Loveland

3850 N Grant Ave Loveland CO 80538

Urgent Care, Physician Offices Poudre Infusion Therapy-JV

915 Centre Ave Fort Collins CO 80526

Infusion Foxtrail Family Medicine

1625 Foxtrail Dr Loveland CO 80538

Physician Offices Family Healthcare of the Rockies

3000 S College Ave St 210 Fort Collins CO 80525

Physician Offices HCORScottsbluff

2 W 42nd St 2200 Scottsbluff NE 69361

Physician Offices PVMG OBGYN

1136 E Stuart St 2100 Fort Collins CO 80525

Physician Offices HCORSteamboat

940 Central Park Dr 290 Steamboat Springs CO 80487

Physician Offices HCOREstes Park

555 Prospect Ave Estes Park CO 80517

Physician Offices HCORFort Morgan

1000 Lincoln Street 207 Fort Morgan CO 80701

Physician Offices Primary Care-Sterling

620 Iris Drive Sterling CO 80751

Physician Offices HCORYuma

910 S Main Street Yuma CO 80759

Physician Offices HCORCraig

595 Russell Street Craig CO 81625

Physician Offices HCORKremmling

214 S 4th Street Kremmling CO 80459

Physician Offices HCORLaramie

3116 Willet Drive Laramie WY 82070

Physician Offices HCORAlliance

2101 Box Butte Ave Alliance NE 69301

Physician Offices HCORWalden

350 McKingley St Walden CO 80480

Physician Offices HCORSidney

1625 Dorwart Drive Sidney NE 69162

Physician Offices Phlebotomy Station

1113 Oakridge Drive Fort Collins CO 80525

PHLEBOTOMY Phlebotomy Station

2001 S Shields Fort Collins CO 80526

PHLEBOTOMY Phlebotomy Station

2025 Big Horn Drive Fort Collins CO 80525

PHLEBOTOMY Phlebotomy Station

3519 Richmond Drive Fort Collins CO 80526

PHLEBOTOMY SCHEDULE H, PART III SECTION A, LINE 4, LINE 5 & LINE 6 LINE 4: Patient accounts receivable are due in full when billed. Accounts are considered delinquent and subsequently written-off as bad debts based on individual credit evaluation and specific circumstances of the account. Bad debt expense at cost was calculated using the cost to charge ratio calculted in worksheet #2 multiplied by bad debt expense reported on the audited financial statements. The Patient Business Service team assists all potentially eligible patients with the application process for financial assistance programs (government and internally sponsored). If the application is completed and the patient is eligible the account balance is not written off to bad debt, instead it is recorded as a charity care adjustment. If the application is not completed we have no way to determine patient eligibility for charity care classification, and the account is written off as bad debt. At this time community benefit does not include any bad debt amounts. LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS: Poudre Valley Health Care Cost Report 58,016,626 Poudre Valley Health Care GME Payment (596,440) Centre Ave Health & Rehab Cost Report 3,422,604 Columbine Poudre Homecare Cost Report 1,256,679 PVHC Inc. Medicare disallowed programs 1,547,067 Disregarded Entities 30,249,235 Joint Ventures 3,478,226 Total to Line 5 97,373,997 LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WERE COMPUTED AS FOLLOWS: Poudre Valley Health Care Cost Report 82,935,258 Centre Ave Health & Rehab Cost Report 5,318,357 Columbine Poudre Homecare Cost Report 1,163,573 PVHC Inc. Medicare disallowed programs 1,954,092 Disregarded Entities 19,867,309 Joint Ventures 3,478,921 Total to Line 6 114,717,510 SCHEDULE H, PART III SECTION B, LINE 8 Approximately 27% of net patient service revenue is from participation in the Medicare program, thus providing Medicare services promotes access to healthcare services to a significant portion of the community population. Line 6: allowable costs as reported on the Poudre Valley Hospital 2010 Cost Report aggregated with disregarded entities and ownership portions of joint ventures. SCHEDULE H, PART III SECTION C, LINE 9B Patient provides documentation based on Colorado Indigent Care guidelines, reviewed by Financial Assistance Committee (FAC), cross functional team chaired by Director Patient Financial Services. Upon approval or denial of the request for charitable aid from the FAC, the patient will be advised of the decision. The bill is partially or totally adjusted as approved by the FAC, no further collection process with the patient. For any portion not adjusted off, the proper sequence of attempts to collect are followed. Final assignment of the bill is to a collection agency. SCHEDULE H, PART VI SUPPLEMENTAL INFORMATION NEEDS ASSESSMENT: We assess the health care needs of the communities we serve in several ways. First, we complete our own Community Health Survey once every three years. This is a blinded survey sent out to 5,000 residents of the communities we serve. This survey is meant to assess the needs of our community and priorities for health prevention, intervention and treatment for the people we serve. Along side of this is an extensive review and assessment of other health data to examine the trends and impact and burden of disease. We partner with the Health District of Northern Larimer County and the Larimer Department of Health and Environment to examine the data and develop action plans to address the needs with high morbidity and mortality rates. We utilize hospital data, state and local health dept. data, the health district survey, and BRFSS data to examine the health issues that affect the people we serve. We utilize the assistance of Epidemiologist to insure correct assumptions based upon the data we review. Our marketing department will also administer specific surveys related to services we offer in the community to see if needs are being addressed. We also administer focus groups for specific areas of focus to ensure we are meeting health needs. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: There is documentation in a billing brochure given to patient/families, self-pay inpatients are screened by the Financial Assistance teams, the monthly statements mention a contact if assistance is needed, and if a patient/family call Patient Billing and inform us they need assistance they are put through the screening process. COMMUNITY INFORMATION: Poudre Valley Health System (PVHS) is a locally owned, private, non-profit organization with a strong Vision: to provide world class healthcare. Based in Northern Colorado, PVHS provides evidence-based healthcare and wellness services and products in Colorado, Nebraska and Wyoming, across a service area covering more than 50,000 square miles. PVHS is a regional medical hub that includes Poudre Valley Hospital, Medical Center of the Rockies, Mountain Crest Behavioral Health Center, Poudre Valley Medical Group, and dozens of associated clinics and outpatient services. The organization's Mission is to be an integrated, independent, non-profit organization providing innovative, comprehensive care of the highest quality while exceeding expectations of the communities we serve. PROMOTION OF COMMUNITY HEALTH: We have implemented a multitude of programs that address the health of our community involving all age groups and focus on what an individual can do to improve his/her health. Also we give dollars to other entities that also work to improve the health of our community. Examples are: primary care for children, activity programs for developmentally disabled adults, obesity prevention, feeding programs for low income, and mental health services for the underserved. AFFILIATED HEALTH CARE SYSTEM: All the services we offer are available to anyone that uses any of our facilities in the health system. Our geography is not that large so we are able to accommodate the different communities that utilize our services with the same level of community health programming. STATE FILING OF COMMUNITY BENEFIT REPORT: We only submit community benefit data in the state of Colorado SCHEDULE H, PART I Part I, Line 7, Column F Total bad debt expense removed from the denominator prior to the percentage calculation = 8,544,809. (8,196,637 reported on Part IX and 348,172 from joint ventures) Part I, Line 7 The organization used a cost-to charge ratio for lines 7a, 7b, and 7c. The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The information for lines 7e through 7i was derived from information in the general ledger and other financial data related specifically to the various types of community benefits. The information for line 7g includes some computations based upon the cost-to-charge ratio mentioned above. Community Building Activities Schedule H Part II As mentioned under promotion of community health we have a multitude programs designed to address the health of our community involving all age groups and focus on what an individual can do to improve his/her health. Many of the programs reflected in Part II are designed to promote healthy options and choices for our comunity which is an important part of overall community health and therefore a benefit to the community. true Poudre Valley Health System Foundation 2315 E Harmony Rd Ste 200 Ft Collins CO 80528 741894581 501(C)(3) 344166 See Sch. I, Part IV American Cancer Society 8221 W 20th A Greeley CO 80634 841316555 501(C)(3) 6000 See Sch. I, Part IV Boys and Girls Club of Larimer Cty 103 Smokey St Ft Collins CO 80525 742425914 501(C)(3) 7160 See Sch. I, Part IV City of Ft Collins PO Box 580 Ft Collins CO 80522 846000587 GOV'T 55000 See Sch. I, Part IV City of Loveland 5th and Lincoln Loveland CO 80537 846000609 GOV'T 55400 See Sch. I, Part IV Colo Ctr for Nursing Excellence 5290 E Yale Cr Ste 102 Denver CO 80222 320022295 501(C)(3) 20000 See Sch. I, Part IV Colorado State University 601 South Howes St Ft Collins CO 80523 846000545 GOVERNMENT 121467 See Sch. I, Part IV Food Bank for Larmier Cty 1301 Blue Spruce Ft Collins CO 80524 742336171 501(C)(3) 19100 See Sch. I, Part IV Front Range Community College 3645 West 112th Ave Westminster CO 80031 841311148 501(C)(3) 200000 See Sch. I, Part IV Ft Collins Museum of Cont Art 200 Mathews Street Ft Collins CO 80524 742541265 501(C)(3) 5638 See Sch. I, Part IV Greeley Centennial Rotary Club PO Box 1472 Greeley CO 80632 840714073 501(C)(4) 7500 See Sch. I, Part IV Loveland Chamber of Commerce 5400 Stone Creek Cr 200 Loveland CO 80538 840254565 501(C)(6) 5275 See Sch. I, Part IV March of Dimes 1325 S Colo Blvd B508 Denver CO 80222 131846366 501(C)(3) 5500 See Sch. I, Part IV Metro Denver Sports Comission 444 ShermanSt 300 Denver CO 80203 202052624 501(C)(3) 25000 See Sch. I, Part IV Nat'l MS Society 900 S Broadway St 250 Denver CO 80209 135661935 501(C)(3) 5300 See Sch. I, Part IV Nine Health Fair 1139 Delaware Street Denver CO 80204 742452969 501(C)(3) 19500 See Sch. I, Part IV Northern Colorado EDC 3553 Clydesdale Parkway 230 Loveland CO 80538 841012341 501(C)(6) 20000 See Sch. I, Part IV Poudre School District 1630 S Stover St Ft Collins CO 80525 846013733 GOVERNMENT 7767 See Sch. I, Part IV Project Self Sufficiency 375 W 37th St 150 Loveland CO 80538 841206341 501(C)(3) 12000 See Sch. I, Part IV Suicide Resource Center of Larmier Cty 315 E 7th St 201 Loveland CO 80537 841194619 501(C)(3) 10000 See Sch. I, Part IV TEAM Ft Collins PO Box 1808 Ft Collins CO 80522 841501128 501(C)(3) 7000 See Sch. I, Part IV University of N Colorado Fdn UNC Campus/Carter Hall Greeley CO 80639 846044833 501(C)(3) 40000 See Sch. I, Part IV Weld Food Bank 1108 H Street Greeley CO 80631 742244826 501(C)(3) 30000 See Sch. I, Part IV PREVENT CANCER FOUNDATION PO BOX 34885 ALEXANDRIA VA 22334 521429544 501(C)(3) 10000 See Sch. I, Part IV 21 3 Purpose of Grant or Assistance Question 1, Part II, Col. H FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. Procedures for monitoring grants Part I Question 2 The organization awards grants based on benefit to the community. The organization requests information from the grantees to ensure that the funds will be used for the specified purpose. X X X false true X X X X X true false false false false false false false false RULON STACEY 1103055 0 1355 0 545069 0 809231 0 25417 0 2484127 0 463840 STEPHANIE DOUGHTY 457031 0 1290 0 6896 0 221550 0 8126 0 694893 0 AUSTIN BAILEY MD 239195 0 1355 0 810 0 24453 0 19829 0 285642 0 MARY BLATTNER MD 294237 0 0 0 1177 0 0 0 7081 0 302495 0 RUSS BRANZELL 328186 0 1061 0 15376 0 121322 0 24662 0 490607 0 PAMELA BROCK 199040 0 1280 0 338257 0 94975 0 18994 0 652546 0 16299 JOSEPH GOTTFRIED MD 230101 0 1280 0 9010 0 14700 0 25448 0 280539 0 DIANE GROSS 69021 0 51 0 381946 0 56528 0 13841 0 521387 0 12277 CRAIG LUZINSKI 242550 0 1903 0 21025 0 84281 0 20825 0 370584 0 GERALD MCINTOSH MD 324456 0 0 0 1167 0 7350 0 14470 0 347443 0 JOHN NAGEL MD 237930 0 1280 0 11070 0 14700 0 16886 0 281866 0 WILLIAM NEFF MD 384367 0 2065 0 4453 0 131669 0 24987 0 547541 0 PATTI OAKES 218112 0 1290 0 684 0 88943 0 7991 0 317020 0 DAN ROBINSON 227744 0 1390 0 2858 0 119844 0 24894 0 376730 0 KEVIN UNGER 351090 0 1290 0 34433 0 180203 0 20290 0 587306 0 BARB YOSSES 292693 0 1024 0 1140 0 143763 0 13419 0 452039 0 TODD WHITSITT MD 261936 0 0 0 1167 0 0 0 8650 0 271753 0 Sch. J, Part 1, Question 1B Reimbursement or provison of expenses Travel for companions: Per system policy travel for companions is not reimbursable. For convenience of travel arrangements for the annual board member retreat, and select conferences, PVHC pays for one companion per board member or invited employee. Each board member receives a 1099 for the related reimbursement. Each employee receives additional compensation on their annual W-2. Gross-Up: Gross Up Payroll is calculated at year end for special checks created to add specific items to employee's W-s wages including country club dues, personal use of cell phones, personal use of laptop computers, spouse travel for annual board retreat and select conferences and imputed income on life insurance policies. Club Dues: The health system expects the hospital management to participate in community life and therefore the system pay social club dues for specific members of the senior management group. The club dues are added to the senior managements W-2 on an annual basis. Sch. J, Part 1, Question 4a PERSONS WHO RECEIVED A SEVERANCE PAYMENT OR CHANGE OF CONTROL PAMELA BROCK: $237,037 DIANE GROSS: $300,698 THESE AMOUNTS REPRESENT SEVERANCE PAY AS PART OF THE EMPLOYMENT TERMINATION AGREEMENT. COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS false false false COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26294807 PAYMENT OF COMMERCIAL PAPER DEBT false false false COLORADO HEALTH FACILITIES AUTHORITY SERIES F 840752932 196474W48 2005-03-31 55343750 REFUNDING 1999A BONDS false false false 0 0 50000000 3222119 0 46468713 433893 3097393 0 0 0 0 false true true true 0 0 26294807 1691575 0 25000000 397052 897754 0 0 0 0 true false true true 0 0 55000000 3571769 0 54542446 795916 0 0 0 0 0 false true true true false true true false true 0.00000 0.00380 0.00380 true true false true JP MORGAN CHASE 25.67 true false false false false true false true JP MORGAN CHASE 30.83 true false false false true false false false false false BOND ISSUE PRICE SCHEDULE K, PART I, COLUMN (E) THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 8038: $83,000,000. KEVIN UNGER Split-$ Life Ins Prm X 262845 247584 false true true CRAIG LUZINSKI Split-$ Life Ins Prm X 291404 255320 false true true RUSS BRANZELL Split-$ Life Ins Prm X 361945 314962 false true true PAM BROCK Split-$ Life Ins Prm X 309493 248239 false true true BILL NEFF Split-$ Life Ins Prm X 203182 191138 false true true DIANE GROSS Split-$ Life Ins Prm X 129166 123730 false true true DAN ROBINSON Split-$ Life Ins Prm X 224926 194345 false true true BARB YOSSES Split-$ Life Ins Prm X 95743 87520 false true true PATTI OAKES Split-$ Life Ins Prm X 52373 49461 false true true STEPHANIE DOUGHTY Split-$ Life Ins Prm X 663050 590155 false true true 2302454 FIRST NATIONAL BANK SCHEDULE O 171094 FEES PAID TO AN ENTITY false NORTHERN COLORADO ANESTHESIA SCHEDULE O 487372 1099 INCOME PAID TO ENTITY false Cyndy Luzinski family member of key emp. 41943 EMPLOYMENT WAGES false JENNA LUZINSKI family member of key emp. 13123 EMPLOYMENT WAGES false KATHLEEN MICHIE FAMILY MEMBER OF DIRECTOR 62951 EMPLOYMENT WAGES false SCOTT OVERLY FAMILY MEMBER OF KEY EMP. 49394 EMPLOYMENT WAGES false TRAVIS WHITSITT FAMILY MEMBER OF DIRECTOR 20401 EMPLOYMENT WAGES false STAMPEDE PROPERTIES SCHEDULE O 228773 1099 INCOME PAID TO ENTITY false INNOVATION ENTERPRISES Officer is key employee 1339757 Interest rent and wage reimb false BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS SCHEDULE L, PART IV NAME OF INTERESTED PERSON: CHRIS OSBORN RELATIONSHIP: DIRECTOR WHO ALSO SERVED AS A DIRECTOR OF FIRST NATIONAL BANK, AN ENTITY TO WHICH FEES WERE PAID. RELATIONSHIP ENDED 6/30/2010 NAME OF INTERESTED PERSON: BILL NEFF RELATIONSHIP: KEY EMPLOYEE WHO ALSO SERVED AS A DIRECTOR FOR NORTHERN COLORADO ANESTHESIA, AN ENTITY TO WHICH 1099 INCOME WAS PAID NAME OF INTERESTED PERSON: DAN STROH RELATIONSHIP: DIRECTOR WHO HAS OWNERSHIP IN STAMPEDE PROPERTIES, AN ENTITY TO WHICH 1099 INCOME WAS PAID X VEHICLES 1 138533 COST X FURNITURE 3 18398 COST X EQUIPMENT 11 203949 COST false true true SCHEDULE M, PART I, LINE 32A USE OF RELATED ORGANIZATIONS TO SOLICIT NON-CASH CONTRIBUTIONS Poudre Valley Health System Foundation, a related organization, receives, administers and distributes cash and non-cash contributions to Poudre Valley Healthcare Inc, other related organizations and the surrounding communities. Process to review 990 Form 990, Part VI, Question 11 The Form 990 is prepared by independent CPAs. A preliminary draft is presented by the organization's CFO to the finance committee of the board of directors for the detailed review. The final copy of the 990 is provided in an electronic format to all board of directors prior to filing with the IRS. How conflict of interest policy is monitored & enforced Form 990, Part VI, Question 12c The organization's conflict of interest policy requires completion of the form on an annual basis by the board members, officers and key employees of the organization. Completed forms are submitted and reviewed by the internal compliance department to ensure compliance with the written policy. Any questions or ultimate enforcement would be handled by the compliance department. Process for determining compensation Form 990, Part VI, Question 15a & 15b Poudre Valley Healthcare, Inc. determines CEO, Executive Director, Top management officials and other officers and key employees compensation annually. This determination is accomplished through the use of Integrated Health Care Strategies services. These services annually collect like data on like jobs from like organizations. The data is submitted to the VP of HR who takes the information to the compensation committee of the governing board of directors where any new compensation is then adopted. How documents are made available to the public Form 990, Part VI, Question 19 Governing documents, conflict of interest policies, and financial statements are provided to the public based on the business purpose for the request. These requests are addressed by the senior management team on a case by case basis. Volunteers Form 990, Part I, Line 6 PVH had 689 active volunteers in 2010. At Poudre Valley Hospital, Medical Center of the Rockies, and off-site locations, volunteers play an integral role in providing much needed support for patients, visitors, physicians, and staff. From assisting in Surgery and Cardiac waiting rooms, Information Desk, Volunteer Patient Liaisons, baby knitters, Volunteens, and pet therapy to name just a few of the many programs. Every volunteer contributes to the success of Poudre Valley Health System to enhance the comfort and care of the patients and their families. POLICIES FORM 990, PART VI, Section B All answers marked "yes" on under policies section B part VI apply to Poudre Valley Health Care Inc. and Lakota Lake LLC. Questions 15a and 15b apply to Timberline Medical LLC as well as Poudre Valley Health Care Inc., Lakota Lake LLC., and Poudre Valley Medical Group, LLC. FORM 990 PART XI OTHER CHANGES IN NET ASSETS OR FUND BALANCES SEE SCHEDULE D PART XI FOR RECONCILIATION OF NET ASSETS Additional Information Form 990, Part VII Todd Whitsitt served as a board member until he became a physician employee of Poudre Valley Medical Group, LLC. His compensation is for physician services. Significant Program Services During Year Which Were Not Listed on 2009 990 Form 990, Part III, Line 2 Poudre Valley Medical Group, LLC was created to integrate Poudre Valley Health System with physician practices, at year end 2010 PVMG, LLC was comprised of 105 employed physicians representing 21 specialities at 17 medical clinics in 22 communities in Colorado, Nebraska and Wyoming HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:STU VANMEVEREN TITLE:BOARD CHAIR HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CHRIS OSBORN TITLE:VICE BOARD CHAIR HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CHRISTINE CHIN TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MIKE DELLENBACH TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:GARY LUDWIN TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:THAINE MICHIE TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:TODD SORENSEN, MD TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:LAURIE STEELE TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DAN STROH TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOE HENDRICKSON TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RULON STACEY TITLE:CHIEF EXECUTIVE OFFICER HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:TODD WHITSITT, MD TITLE:PHYSICIAN, BD MEMBER THRU 3/10 HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CHRIS KNEELAND TITLE:BOARD MEMBER THRU 3/10 HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:LEE THIELEN TITLE:BOARD MEMBER THRU 3/10 HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:STEPHANIE DOUGHTY TITLE:CHIEF FINANCIAL OFFICER HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RUSS BRANZELL TITLE:CHIEF INFORMATION OFFICER HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PAMELA BROCK TITLE:FORMER VP MKTG & STRATEGIC PLN HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DIANE GROSS TITLE:FORMER VP - GENERAL COUNCIL HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CRAIG LUZINSKI TITLE:PVH CHIEF NURSING OFFICER HOURS:4 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:WILLIAM NEFF, MD TITLE:CHIEF MEDICAL OFFICER HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PATTI OAKES TITLE:VP HUMAN RESOURCES HOURS:6 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DAN ROBINSON TITLE:PVH VP OF OPERATIONS HOURS:4 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:KEVIN UNGER TITLE:PVH PRESIDENT HOURS:4 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:BARB YOSSES TITLE:VP AMBULATORY SERVICES HOURS:30 Timberline Medical Clinic 131 Stanley Ave Estes Park CO 80517 043772090 Outpatient CO 1195825 332118 NA Lakota Lake LLC 2315 E Harmony Rd Ste 200 Fort Collins CO 80528 841447761 Outpatient CO 3578469 6721747 NA Heron Lake LLC 2315 E Harmony Rd Ste 200 Fort Collins CO 80528 264189163 Outpatient CO 405247 683420 NA Poudre Valley Medical Group LLC 2315 E Harmony Rd Ste 200 Fort Collins CO 80528 800348943 Outpatient CO 35506890 30052246 NA Medical Center of the Rockies 2315 E Harmony Rd Ste 200 Ft Collins CO 80528 043730045 Tertiary Care CO 501(c)(3) line 3 NA PVHS Foundation 2315 E Harmony Rd Ste 200 Ft Collins CO 80528 741894581 Bene. health CO 501(c)(3) line 7 NA Healthy Start 2315 E Harmony Rd Ste 200 Fort Collins CO 80528 742523091 Inactive Corp CO 501(c)(3) LINE 7 NA CARBON VALLEY HEALTHCARE HOLDINGS 1950 MOUNTAIN VIEW AVE LONGMONT CO 80501 273769602 MEDICAL CO 501(c)(3) Line 3 NA Harmony Surgery Center 2127 E Harmony Rd 200 Ft Collins CO 80528 841479751 Ambulatory Surg CO NA RELATED 1930793 2147829 false false 0.51100 United Medical Alliance 2021 Battlecreek Drive Ste A Ft Collins CO 80528 820572743 Health Claims CO NA RELATED 138660 425590 false false 0.50000 PV Radiation Oncology PO BOX 211367 Denver CO 80221 841537239 Radiation Onc. CO NA RELATED 296019 2182959 false false 0.50000 Center Ave Health & Rehab 947 Worthington Circle Ft Collins CO 80526 841560494 Nursing Facility CO NA RELATED 315329 828839 false false 0.50000 Columbine Poudre Homecare 947 Worthington Circle Ft Collins CO 80526 841529817 Nursing Care CO na RELATED 258687 411418 false false 0.50000 Eye Laser Center of Northern Colo 1725 E Prospect Rd Ft Collins CO 80525 841518334 Laser Surgery CO NA RELATED 14775 -146 false false 0.50000 Gateway Medical Services 2500 E Prospect Rd Ft Collins CO 80525 841427970 Real Est/Med Eq CO NA RELATED 3044818 5905694 false false 0.50000 Poudre Infusion Therapy 947 Worthington Circle Ft Collins CO 80526 841530973 Medical Services CO NA RELATED -64413 152350 false false 0.50000 PVHS Home Medical Supply 6820 N County Rd 13 Loveland CO 80538 202034599 Medical Supply CO NA RELATED -92468 394329 false false 0.50000 MCR SURGERY CENTER 2500 Rocky Mountain Ave Ste 200 LOVELAND CO 80538 250359717 AMBULATORY SVCS CO NA RELATED -905379 0 false false 0.50000 Vein & Laser Center of No Colorado 2008 Caribou Drive Fort Collins CO 80525 204943970 Medical Services CO na Related 16525 false false 0.33330 Harmony Imaging Center 1951 Wilmington Drive Fort Collins CO 80528 582479187 Medical Imaging CO NA Related 897360 1144577 false false 0.46000 Peak Surgical Management LLC 2127 e Harmony RD Ste 200 Fort Collins CO 80528 260899618 Surgical Mgmt CO NA Related 65106 9982 false false 0.10000 Surgery Center of Fort Collins 1100 E Prospect Road Fort Collins CO 80525 841541559 Surgical Proc CO NA Related 706039 1095149 false false 0.26000 MCR SURGERY CENTER 2500 ROCKY MTN AVE STE 2 LOVELAND CO 80538 250359717 AMBULATORY SURG CO NA RELATED -905736 0 false false 0.00000 Innovation Enterprises 2315 E Harmony Rd Ste 200 Fort Collins CO 80528 202036774 IT Consulting CO NA C Corp 1173152 4021745 1.00000 true true true true false true true false true false true true true true true true true true Harmony Surgery Center A 707122 Harmony Surgery Center N 2908387 Harmony Surgery Center P 253214 Harmony Surgery Center R 1915323 MCR Surgery Center N 881579 MCR Surgery Center P 1151204 Poudre Valley Radiation Oncology I 159722 Poudre Valley Radiation Oncology P 58524 Poudre Valley Radiation Oncology r 200000 United Medical Alliance L 1015687 United Medical Alliance R 141147 Centre Ave Health and Rehb R 275000 Columbine Poudre Homecare R 200000 Gateway Medical Services R 3115000 PVHS Home Medical Supply R 3115000 Medical Center of the Rockies K 7859052 Medical Center of the Rockies M 1700444 Medical Center of the Rockies N 67538941 Medical Center of the Rockies Q 79567836 PVHS Foundation B 344166 PVHS Foundation C 461110 PVHS Foundation K 141256 PVHS Foundation N 1353035 Innovation Enterprises A 251548 Innovation Enterprises D 3611352 Innovation Enterprises a 437256 Innovation Enterprises N 650953