2026-05-14T17:22:16-05:00 2025-06-30 460403496 CASEY PETERSON LTD 909 ST JOSEPH ST STE 101 RAPID CITY SD 57701 990 2024-07-01 830300467 POWELL VALLEY HEALTH CARE INC POWE 3077542267 777 AVENUE H POWELL WY 82435 TODD SANDBERG CEO 3077542267 2026-05-14 1 1 KAYLA GIESEY CPA P01874520 6053481930 2026-05-14 2024 2025-03-06 01:10:19Z POWELL VALLEY HOSPITAL TODD SANDBERG 777 AVENUE H POWELL WY 82435 83909862 0 X WWW.PVHC.ORG X 1992 WY PROVISION OF HEALTHCARE SERVICES 12 8 593 28 0 0 536289 116574 82070059 83712239 24089 23419 70406 57630 82700843 83909862 79025 41452 0 0 45896779 45579602 0 0 95832 37903094 45676219 83878898 91297273 -1178055 -7387411 34395565 28698069 8277729 9967644 26117836 18730425 X CARING FOR YOU 0 0 74150797 41452 83769869 POWELL VALLEY HEALTH CARE, INC. (HOSPITAL) PROVIDES QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, DISABILITY, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION TO ALL COMMUNITY MEMBERS. DURING THE YEAR ENDED JUNE 30, 2025, THE HOSPITAL PROVIDED $193,208 OF MEDICAL SERVICES, BASED ON THE AMOUNTS OF CHARGES FOREGONE, UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE (BASED ON COST) OF PROVIDING CARE TO ALL PATIENTS WAS $6,253,454 FOR THE YEAR ENDED JUNE 30, 2025. DURING THE FISCAL YEAR ENDED JUNE 30, 2025, THE HOSPITAL PROVIDED 3,115 DAYS OF HOSPITAL SERVICES, THE NURSING HOME PROVIDED 15,522 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED 7,184 DAYS OF RESIDENT SERVICES. THE HOSPITAL ALSO PROVIDES COMMUNITY CARE AND SERVICES THROUGH MANY HEALTH ACTIVITIES AND PROGRAMS PROVIDED TO SUPPORT THE COMMUNITY. THESE ACTIVITIES INCLUDE SUPPORT TO ONE HEALTH, A COMMUNITY HEALTH CENTER FQHC, WELLNESS PROGRAM, COMMUNITY EDUCATION PROGRAM, SPECIAL PROGRAMS FOR SPECIFIC PURPOSES, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. 74150797 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 46 0 1 593 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 8 0 1 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X THE ORGANIZATION 3077542267 777 AVENUE H POWELL WY 82435 RJ KOST PRESIDENT 1.00 1.00 X X 0 0 0 CHRIS COX VICE PRESIDENT 1.00 1.00 X X 0 0 0 BONITA KATZ SECRETARY 1.00 1.00 X X 0 0 0 NATHANIEL RIEB MD TREASURER 1.00 X X 0 0 0 SYD THOMPSON DIRECTOR 1.00 1.00 X 0 0 0 SHELLY HILL DIRECTOR 1.00 1.00 X 0 0 0 TRACY MORRIS DIRECTOR 1.00 1.00 X 0 0 0 SCOTT MCKENZIE DIRECTOR 1.00 1.00 X 0 0 0 PATTI REISINGER DIRECTOR 1.00 X 0 0 0 KELLY CHRISTENSEN MD DIRECTOR/PHYSICIAN 40.00 X 416096 0 40214 BRADLEY NORTH DO DIRECTOR/PHYSICIAN 40.00 X 421806 0 43769 JENKINS CLARKSON MD DIRECTOR/PHYSICIAN 40.00 X 474315 0 28996 COBY LA BLUE CFO 40.00 X 169895 0 5097 WILLIAM JARVIS PHYSICIAN 40.00 X 916376 0 43769 CARLETTA COLLINS PHYSICIAN 40.00 X 683354 0 42044 TOMASZ OLEJNIK PHYSICIAN 36.00 X 494096 0 33208 LINDSAY CARLSON KLEIN PHYSICIAN 30.00 X 465214 0 42044 CHARLES LAMBIOTTE PHYSICIAN 36.00 X 380432 0 26586 4421584 0 305727 73 0 1 0 BILLINGS CLINIC PO BOX 30977 BILLINGS MT 59107 MANAGEMENT & RADIOLOGY SERVICES 2699960 HOLISTIC PAIN MANAGEMENT PO BOX 1476 LOVELAND CO 80537 PAIN MANAGEMENT SERVICES 1815690 NORTH PLATTE PHYSICAL THERAPY INC PO BOX 1790 DOUGLAS WY 82633 PHYSICAL THERAPY 1558632 340B HOLDINGS LLC 10181 SCRIPPS GATEWAY COURT SAN DIEGO CA 92131 PRESCRIPTION ADMINISTRATION SERVICES 881910 ORTHOPAEDICS OF STEAMBOAT SPRINGS PC 940 CENTRAL PARK DR STEAMBOAT SPRINGS CO 80487 ORTHOPEDIC SERVICES 738388 14 34095 69538 12941 116574 PATIENT SERVICE REVENUE 621110 82463966 82463966 PHARMACY CONTRACT REVENUE 456110 892859 892859 CAFETERIA 722514 220944 220944 OTHER INCOME 621110 134470 134470 83712239 23319 23319 38430 0 38430 38430 38430 100 0 100 100 100 MISCELLANEOUS INCOME 900099 19200 19200 19200 83909862 83769869 0 23419 X 41452 41452 1600187 1425196 174991 33965851 28509899 5374879 81073 679881 541529 135947 2405 7001677 5016333 1984637 707 2332006 1929104 396705 6197 617370 617370 35953 35953 65283 65283 10066109 8880382 1185491 236 219167 165752 53415 216351 138686 74058 3607 1332578 120818 1211760 1473926 739956 733970 125190 110753 14437 132864 31996 100868 1172626 689479 483147 970629 970629 MEDICAL SUPPLIES 18872030 18872030 PROVISION FOR BAD DEBTS 5809548 5809548 PROVISION FOR INSURANCE 3237812 3237812 FOOD 715800 685557 28636 1607 612983 442327 170656 91297273 74150797 17050644 95832 3395230 9336546 17863272 12058353 335327 298645 1706283 2098923 408056 398016 16878665 12371079 5467295 4507586 5220102 0 34395565 28698069 5840711 6234231 6881 6116 2430137 2715767 0 1011530 8277729 9967644 X 26117836 18730425 26117836 18730425 34395565 28698069 -7387411 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 69085 76169 57361 87893 1 X 2255083 927414 1327669 12746597 10532570 2214027 1876985 911095 965890 4507586 ESTIMATED THIRD-PARTY SETTLEMENTS 1011530 1011530 X 78340314 240000 -5809548 -5569548 83909862 0 83909862 85727725 240000 240000 85487725 5809548 5809548 91297273 PART IV, LINE 1B: THE ORGANIZATION IS ACTING AS AN AGENT FOR THE PVHC AUXILIARY PART IV, LINE 2B: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF NURSING HOME RESIDENTS. PART X, LINE 2: AS OF JUNE 30, 2025, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL'S INCOME TAX FILINGS ARE SUBJECT TO AUDIT BY VARIOUS TAXING AUTHORITIES. THE HOSPITAL IS NO LONGER SUBJECT TO FEDERAL AND STATE INCOME TAX EXAMINATIONS BY TAXING AUTHORITIES FOR FISCAL YEARS BEFORE 2022. MANAGEMENT CONTINUALLY EVALUATES EXPIRING STATUTES OF LIMITATION, AUDITS, PROPOSED SETTLEMENTS, CHANGES IN TAX LAW, AND NEW AUTHORITATIVE RULINGS. THE HOSPITAL BELIEVES ESTIMATES ARE APPROPRIATE BASED ON CURRENT FACTS AND CIRCUMSTANCES. INTEREST AND PENALTIES ASSESSED BY INCOME TAXING AUTHORITIES, IF ANY, ARE INCLUDED IN INTEREST EXPENSE. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISIONS FOR BAD DEBTS ARE NETTED AGAINST THE REVENUE IN THE FS -5,809,548. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISIONS FOR BAD DEBTS ARE NETTED AGAINST REVENUE IN THE FS 5,809,548. 1 1 X 1 X 1 X 1 1 0 0 105320 105320 0.00120 5494033 4917623 576410 0.00670 5599353 4917623 681730 0.00790 37 2180 800998 38455 762543 0.00890 16076247 9527526 6548721 0.07660 37 2180 16877245 9565981 7311264 0.08550 37 2180 22476598 14483604 7992994 0.09340 162440 162440 0.00190 162440 162440 0.00190 0 5809548 743622 26424958 28829818 -2404860 X 1 1 1 1 POWELL VALLEY HOSPITAL 777 AVENUE H POWELL WY 82435 X X X POWELL VALLEY HOSPITAL 1 0 0 1 X X X X X X X 24 1 1 1 1 X HTTPS://WWW.PVHC.ORG/ X X 0 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X HTTPS://WWW.PVHC.ORG X HTTPS://WWW.PVHC.ORG X HTTPS://WWW.PVHC.ORG X X X X 1 X 0 X 1 X 0 0 POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 5: HEALTHY PARK COUNTY SENT OUT AND PROMOTED A COMMUNITY HEALTH NEEDS SURVEY WITHIN PARK AND BIG HORN COUNTIES ON BEHALF OF THE COLLABORATION BETWEEN POWELL VALLEY HEALTHCARE, CODY REGIONAL HEALTH, ONE HEALTH, PARK COUNTY PUBLIC HEALTH, AND HEALTHY PARK COUNTY. THE SURVEY WAS COMPLETED BY 952 COMMUNITY MEMBERS WHO SHARED THEIR THOUGHTS REGARDING HEALTH NEEDS. IN ADDITION TO THE SURVEY RESULTS, PVHC USED INFORMATION FROM THE FOLLOWING RESOURCES AS WELL AS INPUT FROM EACH PARTICIPATING ENTITY TO HELP DETERMINE THE TOP SIGNIFICANT HEALTH NEEDS. PARK COUNTY DATA HEALTH INDICATORS COMPARISON COMMUNITY POPULATIONS TOP TEN CAUSES OF DEATH COLETTE MILD - ONE HEALTH HERITAGE RONDA ELIAS PARK COUNTY PUBLIC HEALTH ASHLEY TRUDO CODY REGIONAL HEALTH WENDY MORRIS HEALTHY PARK COUNTY POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 6A: CODY REGIONAL HEALTH POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 6B: ONE HEALTHPARK COUNTY PUBLIC HEALTHHEALTHY PARK COUNTY POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 7D: WE HAVE TV MONITORS IN VARIOUS LOCATIONS ON CAMPUS. THE CHNA IS ADVERTISED THERE, WHERE INDIVIDUALS MAY ACCESS THE DOCUMENT SO GUESTS KNOW THEY CAN READ THE RESULTS ON OUR WEBSITE. POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 11: HEALTHY PARK COUNTY IDENTIFIED FIVE SIGNIFICANT COMMUNITY HEALTH NEEDS. OF THOSE FIVE, POWELL VALLEY HEALTHCARE (PVHC) HAS SET FORTH GOALS TO HELP ADDRESS CANCER AND OBESITY/PHYSICAL ACTIVITY. TO ADDRESS THE CANCER NEED, PVHC WILL MOVE TO ENHANCE AWARENESS FOR THE IMPORTANCE OF CANCER SCREENINGS AND THEIR ROLE IN EARLY DETECTION AND PREVENTION. PVHC'S GOAL IS TO INCREASE SCREENING RATES FOR BOTH BREAST CANCER AND COLORECTAL CANCER. PVHC BEGAN OFFERING FREE BREAST EXAMS IN OCTOBER 2025 AND RECOGNIZED AND PROMOTED COLORECTAL CANCER IN MARCH 2026. TO ADDRESS OBESITY/PHYSICAL ACTIVITY PVHC HOSTED THE SUMMER FOOD PROGRAM WHICH PROVIDES A HEALTHY FREE MEAL TO YOUTH DURING THE SUMMER MONTHS. IN A CONTINUED EFFORT TO SUPPORT AND ADDRESS PHYSICAL ACTIVITY PVHC CONTINUES TO SUPPORT YOUTH AND ADULT SPORTS BY SPONSORSHIPS AND PROVIDING ATHLETIC TRAINERS ACROSS OUR LOCAL HIGH SCHOOLS, MIDDLE SCHOOLS AND THE COLLEGE. PVHC CHOSE TO ADDRESS THESE TWO SPECIFIC NEEDS THAT WOULD HAVE THE GREATEST IMPACT WITH THE RESOURCES AVAILABLE. POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 13B: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY. POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 16J: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE COMMUNITY ON THE HOSPITAL'S WEBSITE, ATTACHED TO BILLING INVOICES, POSTED IN THE HOSPITAL EMERGENCY ROOM AND WAITING ROOMS, POSTED IN THE HOSPITAL ADMISSIONS OFFICES, AND PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL. 3 1 - POWELL VALLEY CLINIC 777 AVENUE H POWELL WY 82435 OUTPATIENT PHYSICIAN CLINIC 2 - POWELL VALLEY CARE CENTER 777 AVENUE H POWELL WY 82435 NURSING HOME 3 - HEARTLAND ASSISTED LIVING 777 AVENUE H POWELL WY 82435 ASSISTED LIVING FACILITY PART I, LINE 3C: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY PART I, LINE 6B. THE COMMUNITY BENEFIT REPORT IS POSTED ON THE ORGANIZATION'S WEBSITE. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST TO THE CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. THE EXPENSES ASSOCIATED WITH COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E WERE DETERMINED USING AN AVERAGE HOURLY RATE FOR STAFF TIME, SPACE USE, AND AMBULANCES. CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS, LINE 7I, WERE REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION ON PART 1, LINE 7 COLUMN F WAS $5,809,548. PART II, COMMUNITY BUILDING ACTIVITIES: POWELL VALLEY HEALTHCARE (PVHC) PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING MENTAL HEALTH RESOURCES THOUGH A MENTAL HEALTH PROVIDER ON SITE. PVHC ALSO OFFERS SERVICES SUCH AS CARDIAC AND PULMONARY REHAB, 24 HOUR AMBULANCE/ER, INFUSIONS, AND DIABETIC EDUCATION. ADDITIONALLY, PVHC HAS A LONG TERM CARE CENTER AND ASSISTED LIVING FACILITY THAT HELPS WITH PROVIDING RESOURCES CLOSE TO HOME FOR THE AGING POPULATION. PART III, LINE 3: THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 12.8% (BASED UPON US CENSUS BUREAU QUICKFACTS FOR PERCENTAGE OF CITIZENS BELOW THE POVERTY LEVEL IN THE CITY OF POWELL, WY). THIS REPRESENTS A REASONABLE PERCENTAGE OF INDIVIDUALS WHO POTENTIALLY QUALIFY FOR CHARITY CARE, BUT MAY NOT HAVE APPLIED AND THEREFORE WERE WRITTEN OFF TO BAD DEBT. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR. THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE IS FOUND ON PAGES 21-22 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. POWELL VALLEY HEALTH CARE PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM WITH THE KNOWLEDGE THAT THE COST REIMBURSEMENTS WILL NOT RESULT IN RECOVERY OF ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 9B: POWELL VALLEY HEALTH CARE, INC. TRIES TO DETERMINE IF A PATIENT NEEDS FINANCIAL ASSISTANCE BEFORE SERVICES ARE RENDERED, EXCEPT IN EMERGENCY SITUATIONS. NO PATIENT IS DENIED ACUTE CARE IN AN EMERGENCY SITUATION. THE HEALTH CENTER WILL PURSUE ALL POSSIBLE FORMS OF THIRD-PARTY PAYMENTS SUCH AS INSURANCE, STATE MEDICAID PROGRAMS, AND COUNTY INDIGENT CARE PROGRAMS BEFORE GRANTING FINANCIAL ASSISTANCE. COLLECTION EFFORTS ARE NOT PURSUED DURING THIS TIME. COLLECTION EFFORTS ARE NOT PURSUED WHILE A COMPLETED CHARITY CARE APPLICATION IS UNDER REVIEW. DECISIONS ON CHARITY CARE APPLICATIONS ARE MADE WITHIN 30 DAYS OF THE COMPLETED APPLICATION. ONCE A DECISION IS MADE, ANY PERSONAL PORTION DUE WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER ACCOUNTS. IF A DETERMINATION FOR FINANCIAL ASSISTANCE IS MADE ON AN ACCOUNT OR FURTHER INSURANCE PROCESSING IS NEEDED AFTER AN ACCOUNT IS SENT TO COLLECTIONS, ALL COLLECTION EFFORTS WILL CEASE AND ANY NEGATIVE REPORTING WILL BE REVERSED. PART VI, LINE 2: POWELL VALLEY HEALTH CARE IS SERVED BY A PUBLICLY ELECTED DISTRICT BOARD. THE BOARD MEMBERS ACTIVELY PROVIDE INFORMATION RELATIVE TO THE HEALTH CARE NEEDS OF THE COMMUNITY. ADDITIONALLY, WE SURVEY PATIENTS, RESIDENTS, AND THEIR FAMILIES AND IN DOING SO, LOOK FOR TRENDS AND/OR SUGGESTIONS FOR IMPROVEMENTS/EXPANSION/OR INITIATION OF SERVICES. POWELL VALLEY HEALTHCARE REGULARLY MONITORS VARIOUS RESOURCES FOR MARKET DATA, TRENDS, AND PATIENT FEEDBACK TO ASSESS THE HEALTH CARE REGIONAL NEEDS. PART VI, LINE 3: POWELL VALLEY HEALTHCARE (PVHC) HAS FINANCIAL ASSISTANCE PAMPHLETS AVAILABLE FOR PATIENTS TO TAKE AT THE ER REGISTRATION DESK AND OFFER RESOURCES AT THE TIME OF VISITS. ALL BILLING STATEMENTS PROVIDE OUR PATIENTS WITH INFORMATION TO ACCESS FINANCIAL ASSISTANCE, AND A FINANCIAL COUNSELOR IS AVAILABLE FOR QUESTIONS AND SUPPORT. ADDITIONALLY, THE FINANCIAL ASSISTANCE POLICY AND APPLICATION ARE BOTH AVAILABLE ON THE POWELL VALLEY HEALTHCARE WEBSITE. PART VI, LINE 4: POWELL VALLEY HEALTHCARE (PVHC) PRIMARILY SERVES PARK COUNTY, WYOMING, WHICH HAS A POPULATION OF 30,109 AS OF 2023. ACCORDING TO THE 2025 CHNA, DEMOGRAPHICS ARE AS FOLLOWS; 8.4% PERSONS IN POVERTY, 88.3% WHITE, NON-HISPANIC AND 4.4% HISPANIC. UNEMPLOYMENT RATE OF 3.2%, 20-22% AND A POPULATION GREATER THAN 65. THE LEADING CAUSE OF DEATH IN WYOMING IS HEART DISEASE AND CANCER. PARK COUNTY HAS IDENTIFIED MENTAL HEALTH AND CANCER AS TWO SIGNIFICANT HEALTH NEEDS.POWELL VALLEY HEALTHCARE IS A 25-BED CRITICAL ACCESS HOSPITAL, 100-BED INTERMEDIATE CARE NURSING FACILITY, A 24-APARTMENT ASSISTED LIVING FACILITY, AND A PHYSICIANS CLINIC LOCATED IN THE NORTHWEST CORNER OF WYOMING, 75 MILES EAST OF YELLOWSTONE NATIONAL PARK, AND 98 MILES SOUTH OF BILLINGS, MT. POWELL HAS A DIVERSE COMMERCIAL, INDUSTRIAL, EDUCATIONAL, AND AGRICULTURAL/RANCHING BASED ECONOMY. IN 2025, 12.8% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $63,523 AND THE POPULATION WAS 6,551. THE NEAREST CITY WITH A POPULATION OF 50,000+ IS BILLINGS, MT. THE NEAREST HOSPITALS ARE NORTH BIG HORN HOPSITAL DISTRICT, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 22 MILES NORTHEAST AND WEST PARK HOSPITAL, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 25 MILES SOUTHWEST. NET REVENUE FROM MEDICARE AND MEDICAID ACCOUNT FOR 34.51% AND 4.30% OF TOTAL NET REVENUE, RESPECTIVELY. PART VI, LINE 5: POWELL VALLEY HEALTHCARE (PVHC) IS COMMITED TO THE COMMUNITY BY PROVIDING A NUMBER OF OTHER UNIQUE SUPPORT SERVICES. PVHC EMPLOYS ATHLETIC TRAINERS WHOM SUPPORT LOCAL SCHOOL DISTRICTS FOR SPORTING FUNCTIONS. PVHC PROVIDES AMBULANCE STANDBY AT LOCAL FOOTBALL AND WRESTLING EVENTS AND ALSO HAVE A DAILY PRESENCE DURING THE COUNTY FAIR. PVHC EMS PROVIDES "STOP THE BLEED" EDUCATION TO THE COMMUNITY AND SCHOOLS, AND PVHC'S OB COORDINATORS EDUCATE HIGH SCHOOL STUDENTS IN OUR COMMUNITY. 1 TUITION REIMBURSEMENTS 11 41452 PART I, LINE 2: THE ORGANIZATION PROVIDED TUITION REIMBURSEMENT TO EMPLOYEES. TUITION REIMBURSEMENTS ARE PAID OUT AT 50% OF TUITION AFTER EMPLOYEES SHOW PASSING GRADES. X 0 0 0 0 0 1 0 0 0 WILLIAM JARVIS PHYSICIAN 650000 0 183091 0 83285 0 12075 0 31694 0 960145 0 0 0 CARLETTA COLLINS PHYSICIAN 650000 0 33354 0 0 0 10350 0 31694 0 725398 0 0 0 TOMASZ OLEJNIK PHYSICIAN 387138 0 72105 0 34853 0 10350 0 22858 0 527304 0 0 0 LINDSAY CARLSON KLEIN PHYSICIAN 425778 0 15000 0 24436 0 10350 0 31694 0 507258 0 0 0 JENKINS CLARKSON MD DIRECTOR/PHYSICIAN 328255 0 51000 0 95060 0 12075 0 16921 0 503311 0 0 0 BRADLEY NORTH DO DIRECTOR/PHYSICIAN 300106 0 116810 0 4890 0 12075 0 31694 0 465575 0 0 0 KELLY CHRISTENSEN MD DIRECTOR/PHYSICIAN 228290 0 176343 0 11463 0 13200 0 27014 0 456310 0 0 0 CHARLES LAMBIOTTE PHYSICIAN 330720 0 49712 0 0 0 10350 0 16236 0 407018 0 0 0 COBY LA BLUE CFO 169895 0 0 0 0 0 5097 0 0 0 174992 0 0 0 PART I, LINE 3 THE ROLE OF THE CEO IS FILLED BY A MANAGEMENT COMPANY. THE BOARD OF DIRECTORS APPROVES THE CONTRACT FOR SERVICES WITH THE MANAGEMENT COMPANY. PART I, LINE 6 BONUSES ARE CALCULATED AS A PERCENTAGE OF NET REVENUE PER QUARTER PER CONTRACT FOR EACH INDIVIDUAL BASED ON BILLED CHARGES FOR THAT QUARTER. STEPHEN KATZ HUSBAND OF BOARD MEMBER BONITA KATZ 444905 COMPENSATION & BENEFITS 0 FORM 990, PART VI, SECTION A, LINE 3 THE ROLE OF THE CEO IS FILLED BY A MANAGEMENT COMPANY. THE BOARD OF DIRECTORS APPROVES THE CONTRACT FOR SERVICES WITH THE MANAGEMENT COMPANY. FORM 990, PART VI, SECTION A, LINE 7A SEVEN BOARD MEMBERS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES SHALL BE APPOINTED BY VIRTUE OF THEIR ELECTION TO THE HOSPITAL DISTRICT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B A BOARD MEMBER WHO IS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES MAY ONLY BE REMOVED BY ACTION OF THE DISTRICT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF FORM 990 IS PROVIDED TO THE CEO AND CFO TO REVIEW. THE CEO OR CFO WILL EITHER MAKE CHANGES OR APPROVE THE FORM 990. AFTER THE FORM 990 IS FINALIZED BUT PRIOR TO BEING FILED, A COPY WILL BE PROVIDED TO THE BOARD OF DIRECTORS AT A BOARD MEETING OR VIA ELECTRONICALLY DELIVERY. FORM 990, PART VI, SECTION B, LINE 12C INDIVIDUALS COVERED BY THE CONFLICT OF INTEREST POLICY INCLUDE MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES (IF APPLICABLE). THE PROCESS USED TO DETERMINE IF ANY CONFLICTS OF INTEREST EXIST CONSISTS OF SENDING THE MEMBERS A DOCUMENT FOR THEM TO COMPLETE PRIOR TO THE BOARD OF DIRECTORS MEETING. EACH INDIVIDUAL COMPLETES THE DOCUMENT WHICH ENTAILS DISCLOSING ANY POSSIBLE CONFLICTS AND RETURNS FOR REVIEW TO THE PRESIDENT OF THE BOARD. IF A MEMBER HAS A CONFLICT THEY ARE NOT ALLOWED TO VOTE ON THE CONFLICTED ISSUES. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION OF THE CEO IS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC BY REQUEST. THE PUBLIC MAY REQUEST A COPY BY CALLING, VIA MAIL, OR WALK-IN. FORM 990, PART IX, LINE 11G CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 8,880,382. MANAGEMENT AND GENERAL EXPENSES 1,185,491. FUNDRAISING EXPENSES 236. TOTAL EXPENSES 10,066,109. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR. POWELL HOSPITAL DISTRICT #1 777 AVENUE H POWELL WY 82435 830200759 RELATED - PROVISION OF HEALTH CARE SERVICES WY GOVERNMENT N/A N/A 0 POWELL MEDICAL FOUNDATION PO BOX 801 POWELL WY 82435 742275540 PROMOTE PUBLIC HEALTH AND IMPROVE FACILITIES AROUND THE CITY OF POWELL, WY WY 501(C)(3) LINE 8 N/A 0 0 0 1 1 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 POWELL MEDICAL FOUNDATION C 34095 CASH PAID POWELL HOSPITAL DISTRICT D 1887 RECEIVABLES FROM PHD AT YEAR END POWELL MEDICAL FOUNDATION D 76 RECEIVABLES FROM PMF AT YEAR END POWELL HOSPITAL DISTRICT K 570000 ACTUAL RENT PAID FOR BUILDINGS POWELL HOSPITAL DISTRICT N 240000 FMV OF DONATED USE OF FACILITIES POWELL MEDICAL FOUNDATION O 95832 CASH PAID BY PVHC FOR PMF'S EXP