2014-05-15T12:54:22-05:00 2013-06-30 BKD LLP 6120 S Yale 1400 Tulsa OK 741364223 990 2012-07-01 731023826 SAYRE MEMORIAL HOSPITAL % SAYRE MEMORIAL HOSPITAL SAYR 5809285541 911 Hospital Drive Suite SAYRE OK 73662 DONNA GAIL ROBISON 5809285541 2014-05-15 true 9185842900 2012 2015-11-30 17:44:51Z DONNA GAIL ROBISON 911 Hospital Drive Sayre OK 73662 7071547 false X WWW.SAYREHOSPITAL.ORG X 1977 OK TO PROVIDE COST-EFFECTIVE, QUALITY MEDICAL CARE FOR SAYRE AND THE SURROUNDING COMMUNITIES IN ORDER TO ACHIEVE LIFE ENRICHMENT FOR THE COMMUNITY THROUGH LOCAL ACCESS TO QUALITY CARE. 6 6 169 10 0 0 499160 546878 7256878 5404542 14395 2468 798787 1117659 8569220 7071547 5500 750 0 0 5171628 3619378 0 0 0 5798162 5559587 10975290 9179715 -2406070 -2108168 17402154 15002315 13378847 13535353 4023307 1466962 TO PROVIDE COST-EFFECTIVE, QUALITY MEDICAL CARE FOR SAYRE AND THE SURROUNDING COMMUNITIES IN ORDER TO ACHIEVE LIFE ENRICHMENT FOR THE COMMUNITY THROUGH LOCAL ACCESS TO QUALITY CARE. false false 7055477 7071547 RURAL HOSPITAL PROVIDING MEDICAL CARE ON BOTH AN IN AND OUTPATIENT BASIS TO AREA RESIDENTS. CARE PROVIDED INCLUDES EMERGENCY, OBSTETRICS, SURGICAL AND PHYSICAL REHABILITATION. CARE IS PROVIDED REGARDLESS OF RACE, CREED, COLOR OR ABILITY TO PAY. 7055477 true true false true false false false false false false true false false false true false true false false false false false false false false false true true false false true false false false false false false false false false false false false false true false false false true 47 0 true 169 true false false false false false false false false false false false false false X 6 6 false true false false true true false true true false false true true true true true true true true false OK X SAYRE MEMORIAL HOSPITAL 5809285541 911 HOSPITAL DRIVE SAYRE OK 73662 ROBERTA OLDFIELD 10.0 X X 0 0 ROBERT LAKEY 10.0 X 0 LEON WILLSIE 10.0 X X KENNETH WHINERY MD 10.0 X GENE MOSES 10.0 X MICHAEL BLEVINS 10.0 X X WALLACE BOYD 40.0 X 33957 3016 CAROLE JACKSON 40.0 X 28584 0 606 MISTY CARTER 40.0 X 24410 0 1231 JIM GROCHOLSKI 40.0 X 0 0 RON VESTAL 40.0 X 76356 0 5514 BRIAN DENTON 40.0 X TREVA GRAHAM MD 40.0 X 103846 0 2068 DR MICHAEL ROBINSON 40.0 X 280501 0 5038 JESSICA L KENNEMER 40.0 X 64425 0 3106 612079 0 20579 2 false true false CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SUPPORT 363478 NP Care Inc 2220 Cherrybrook St DUNCAN OK 73533 Nurse Practioner 184278 MERCY SPECIALIZED BILLING SVCS PO BOX 505125 ST LOUIS MO 63150 BILLING SERVICES 139533 BENISH ASSOCIATES 1716 RIDGEMONT DRIVE WICHITA FALLS TX 76309 PHYSICIAN ASSISTANTS 187986 GE Medical Systems PO Box 843553 DALLAS TX 75284 Info Technology 121356 6 533276 13602 546878 Net Patient Service Revenue 621300 5404542 5404542 5404542 2468 2468 0 0 0 0 0 0 0 0 0 Cafeteria 722210 33945 33945 Medical Records 900099 969 969 Other Related Income 900099 1082745 1082740 5 1117659 7071547 6487282 37387 0 750 750 0 0 349487 243993 105494 0 2727444 1904153 823291 0 286200 199809 86391 256247 178898 77349 97250 97250 0 90645 90645 0 0 0 196657 137295 59362 9130 6374 2756 66082 46300 19782 163270 113986 49284 0 259999 181517 78482 69934 48824 21110 0 0 840349 840349 0 1284114 1284114 188461 188461 Medical Purchased Services 806542 806542 Pharmacy 166614 166614 Medical Supplies 376182 376182 Repairs & Maintenance 252037 175959 76078 692321 343818 348503 9179715 7055477 2124238 0 510651 115539 2771 0 1406785 1406785 1931988 1494990 0 0 0 0 0 0 153228 135905 74928 65767 21655757 9872428 12873626 11783329 0 0 0 0 448177 0 0 0 0 0 17402154 15002315 808528 885770 0 0 0 0 0 0 0 0 0 0 0 0 12414410 12149583 155909 500000 13378847 13535353 X 2168345 60177 1854962 1406785 0 0 4023307 1466962 17402154 15002315 X -2108168 -448177 X false false false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 7323 false false false 7323 false 1 Line 1f The organization pays dues to AHA and OHA and a portion of the dues paid is attributable to lobbying expense. 143835 143835 14442532 4370057 10072475 1377081 559456 817625 5587144 4942915 644229 105165 105165 11783329 0 DUE FROM TAX-EXEMPT AFFILIATE 500000 500000 true true true X 300. true X true true true false false 62864 62864 0.00680 823119 484733 338386 0.03690 885983 484733 401250 0.04370 885983 484733 401250 0.04370 false 1806414 1667959 1776100 -108141 X true true 1 1 SAYRE MEMORIAL HOSPITAL

911 HOSPITAL DRIVE SAYRE OK 73662

X X X SAYRE MEMORIAL HOSPITAL 1 true X X X X X X X X X 12 true false true X X X X X false false true true 300. true 300. true X X X true true X X true false X X X X true X X X X false true 1 SCHEDULE H, PART III, LINE 9B IF A PATIENT IS DETERMINED TO BE FINANCIALLY INDIGENT, PATIENT FINANCIAL SERVICES WILL ASSIST THE PATIENT/GUARANTOR IN APPLYING FOR FINANCIAL ASSISTANCE. IF NO SOURCE OF FINANCIAL ASSISTANCE IS AVALIABLE, THE HEATH CARE CENTER WILL REVIEW THE ACCOUNT FOR CHARITY ALLOWANCE. 2 SCHEDULE H, PART VI, LINE 2 SAYRE MEMORIAL HOSPITAL IS VERY INVOLVED IN EVERY ASPECT OF THE COMMUNITY AND THROUGH THAT INVOLVEMENT AND THE ANNUAL HEALTH FAIR THAT WE ARE ABLE TO PROVIDE FOR THE COMMUNITY, WE TAKE TIME TO LISTEN TO THE HEALTH CARE WANTS AND NEEDS OF OUR CITIZENS. WE UNDERSTAND THAT A GOOD SHARE OF OUR POPULATION IS ELDERLY AND THEY HAVE LIMITED MEANS OF TRAVEL TO A LARGE AREA FOR HEALTH CARE. THEREFORE, WE STRIVE TO PROVIDE A WIDE DIVERSITY OF SERVICES TO MEET AS MANY OF THEIR NEEDS LOCALLY AS WE ARE FISCALLY ABLE TO DO SO. 3 SCHEDULE H, PART VI, LINE 3 UNINSURED INDIVIDUALS ARE PROVIDED COMPUTER ACCESS TO THE MEDICAID SYSTEM TO APPLY FOR ASSISTANCE AT THE TIME OF ADMISSION. WE ALSO PROVIDE A PATIENT ACCOUNT MANAGER WHO INFORMS THE PATIENT OF THE ORGANIZATION'S CHARITY CARE POLICY. 4 SCHEDULE H, PART VI, LINE 4 SAYRE MEMORIAL HOSPITAL PROVIDES CARE TO THE RURAL COMMUNITIES OF SAYRE, ERICK, CHEYENNE, SWEETWATER, CARTER, MANGUM, AND DELHI. OUR PATIENTS ARE 60% MEDICARE, 8% MEDICAID, 22% COMMERCIAL INSURANCE, AND 10% UNINSURED. 5 SCHEDULE H, PART VI, LINE 5 GOVERNING BOARD MEMBERSHIP IS OPEN TO ANYONE OVER THE AGE OF 18 YEARS WHO IS DULY ELECTED. ALL MEMBERS IN GOOD STANDING ARE ENTITLED TO ONE VOTE IN ANY REGULAR OR SPECIAL MEETING AND TO EXERCISE ALL OTHER PRIVILEGES OF MEMBERSHIP. THE MEMBER HAVE THE POWER, BY MAJORIY VOTE, AT REGULAR, SPECIAL CALLED, OR ANNUAL MEETINGS, TO REMOVE ANY DIRECTOR OR OFFICER FROM OFFICE. THERE IS AN ANNUAL MEETING HELD TO ELECT THE BOARD OF DIRECTORS AND OFFICERS AND TO TRANSACT ANY BUSINESS THAT MAY COME BEFORE THE MEETING. OUR MEDICAL STAFF IS OPEN TO ANY LICENSED PHYSICIAN. USE OF SURPLUS FUNDS ARE INVESTED BACK INTO THE HOSPITAL FOR FURTHER CONTINUATION OF SERVICE. 6 Schedule H, Part V, Section B, Line 20D Max charge equals 60% of gross charges (40% discount). 7 Schedule H, Part V, Line 22 Gross charges are identical for FAP-eligible patients vs. non-FAP eligible patients. Once an FAP-eligible patient is determined to meet the criteria for financial assistance, the discounts are then applied. 8 SCHEDULE H, PART V, SECTION B, LINE 3 Citizens of the community were involved in a community survey conducted by the Turning Point Coalition, Oklahoma Unified Resources. Leadership from the Sayre Memorial Hospital are active members of the Oklahoma United Resources Turning Point Coalition. Those that serve in leadership at Sayre Memorial Hospital have special knowledge and expertise in public health. 9 SCHEDULE H, PART V, SECTION B, LINE 5A WWW.SAYREHOSPITAL.ORG 10 Schedule H, Part III, Line 8 The shortfall should be treated as community benefit because caring for Medicare patients fulfills a community need and relieves a government burden as these patients typically have low and/or fixed incomes. cost of providing care for these patients and that shortfall of $X should be counted as community benefit. 11 Schedule H, Part V, Section B, Line 7 There were a couple of needs identified in the community health needs assessment that will not be addressed in the current implementation strategy. The hospital does not have enough resources to address the routine dental care and school health needs in the community. X false false false false false false false false false DR MICHAEL ROBINSON 280501 0 0 0 0 0 0 0 5038 0 285539 0 0 0 1 Form 990, Part VI, Lines 6 and 7a Membership is open to any person over the age of 18 years who is duly elected. All members in good standing are entitled to one vote in any regular or special meeting, and to exercise all other privileges of membership. The members have the power, by a majority vote, at any regular, special called, or annual meeting, to remove any director or officer from office. There is an annual meeting held to elect the Board of Directors and officers and to transact any business that may come before the meeting. 2 Form 990, Part VI, Line 10 The Board of Directors will review the Form 990 prior to filing the return with the IRS. The review will be documented in the board minutes. 3 Form 990, Part VI, Line 12c Officers and trustees are required to disclose annually interests that could give rise to conflicts. 4 Form 990, Part VI, Line 15 The CEO is not an employee of the organization and is compensated by an unrelated organization. The CFO's compensation is reviewed and approved by the board. 5 Form 990, Part VI, Line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. 6 Form 990, Page 12, Line 9 Beneficial Interest in SMH Foundation ($448,177) 7 Form 990, Part IV, line 12a and Form 990 Part XII, Line 2 The organization is currently undergoing a financial statement audit. However, the organization's audit was not completed by the due date of the tax return. Therefore the June 30, 2012 audited financials have been attached to the return as required. SAYRE MEMORIAL HOSPITAL FOUNDATION 911 HOSPITAL DR SAYRE OK 73662 320177689 SUPPORT HOSP. OK 501(C)(3) 9 NA false false false true false false false false false false false false false false false false false false false false