2014-05-09T11:24:39-05:00 2013-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2012-07-01 860334996 BISBEE HOSPITAL ASSOCIATIONINC BISB 5204325383 101 COLE AVENUE BISBEE AZ 856031327 JAMES DICKSON 5204325383 2014-04-23 1 DAVID B BARBER CPACFE P00348638 5206248229 2012 2015-11-30 17:44:51Z COPPER QUEEN COMMUNITY HOSPITAL JAMES DICKSON 101 COLE AVENUE BISBEE AZ 856031327 24908392 0 X WWW.CQCH.ORG X 1977 AZ TO PROVIDE HEALTHCARE SERVICES TO THE BISBEE, DOUGLAS, AND PALOMINAS ARIZONA COMMUNITIES. 11 11 280 13 0 0 1107741 682009 23479236 24137619 -8408 -2907 93938 73113 24672507 24889834 44789 0 0 0 12482967 12951178 0 0 0 8442495 9497321 20970251 22448499 3702256 2441335 21717401 29345161 6364264 11550689 15353137 17794472 TO PROVIDE HEALTHCARE SERVICES TO THE BISBEE, DOUGLAS, AND PALOMINAS ARIZONA COMMUNITY. 0 0 18553627 24155040 TO PROVIDE HEALTHCARE SERVICES THROUGH IN-PATIENT, OUT-PATIENT,24-HOUR EMERGENCY SERVICES AND RURAL HEALTH CLINICS TO THE RESIDENTS OF BISBEE & SURROUNDING COMMUNITIES. 18553627 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 76 0 1 280 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 1 0 AZ X X THE ORGANIZATION 5204325383 101 COLE AVENUE BISBEE AZ 856031327 KATHLEEN HEARD 1.00 X 0 0 0 JOHN HARRIS 1.00 X 0 0 0 ROSALIE BUTLER 1.00 X 0 0 0 DENNIS GALLUS 1.00 X 0 0 0 DENNIS NELSON 1.00 X 0 0 0 LAURA CHAVEZ 1.00 X 0 0 0 GARY DILLARD 1.00 X 0 0 0 PETER CARBERRY 1.00 X 0 0 0 ROBERT HOWELL 1.00 X 0 0 0 LAWANA DIFFIE 1.00 X 0 0 0 ROSA ANEL LOPEZ 1.00 X 0 0 0 JAMES DICKSON 40.00 X 332569 0 26793 DIANE MOORE 40.00 X 135944 0 11047 JOSE ROMO 40.00 X 333652 0 16978 HEIDI LODGE 40.00 X 286704 0 15570 DANIEL ROE 40.00 X 500599 0 21987 BRUCE CURTIS 40.00 X 341778 0 17222 W PATRICK COGHLAN 40.00 X 200358 0 12980 2131604 0 122577 19 0 1 0 WAYTUK JOHN P MD 4119 E SELLS DR PHOENIX AZ 85018 MEDICAL 232700 SIEMENS HEALTHCARE DIAGNOSTICS PO BOX 121102 DALLAS TX 75312 DIAGNOSTIC 231498 LABORATORY LAB OF AMERICA PO BOX 12140 BURLINGTON NC 27216 LAB 213049 CHG COMPANIES INC 6440 SOUTH MILLROCK DRIVE SUITE 17 SALT LAKE CITY UT 84121 STAFFING 201757 DLR GROUP 177 N CHRUCH AVE TUCSON AZ 85701 ARCHITECT 132856 8 19785 651758 10466 682009 PATIENT SERVICE REVENUE 900099 24137619 24137619 24137619 8767 8767 11674 -11674 -11674 -11674 2100 19785 6884 -4784 -4784 CAFETERIA 900099 55465 55465 MISC. REVENUE-RELATED-990 900099 17421 17421 MEDICAL RECORDS 900099 5011 5011 77897 24889834 24155040 0 52785 X 506355 506355 10320339 9209117 1111222 167866 157286 10580 1241012 984417 256595 715606 610176 105430 129439 4275 125164 88280 88280 2433084 1700265 732819 313733 313733 76447 42607 33840 83631 63472 20159 138041 108913 29128 155146 155146 1235781 1235781 349675 349675 PROVISION FOR UNCOLLECT 1790528 1790528 SUPPLIES 1700456 1646818 53638 REPAIRS & MAINTENANCE 273943 232994 40949 UTILITIES 244804 244804 484333 367028 117305 22448499 18553627 3894872 0 3262309 5466292 2054465 3642059 4316882 4666694 530035 651564 202473 124198 23977323 9230323 10801723 14747000 500000 49514 47354 21717401 29345161 2795601 2903254 3568663 8647435 6364264 11550689 X 15288895 17731756 64242 62716 15353137 17794472 21717401 29345161 2441335 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1276610 1276610 15441071 5146405 10294666 6586866 4083918 2502948 672776 672776 14747000 LONG-TERM DEBT 8647435 8647435 X 24908392 18558 18558 24889834 0 24889834 22467057 18558 18558 22448499 0 22448499 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL RECEIVED ITS LETTER OF DETERMINATION FROM THE INTERNAL REVENUE SERVICE IN 1977. CERTAIN UNRELATED BUSINESS INCOME MAY BE SUBJECT TO INCOME TAX. THE HOSPITAL FOLLOWS FASB CODIFICATION 740-10-50 FOR DISCLOSURE OF INCOME TAX RELATED MATTERS. THE STANDARD SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES IN THE ACCOMPANYING FINANCIAL STATEMENTS FOR UNCERTAIN INCOME TAX POSITIONS. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 6,884. LOSS FROM SALE OF ASSETS 11,674. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 6,884. LOSS FROM SALE OF ASSETS 11,674. GOLF TOURNAMENT 21885 19785 2100 4595 2289 21885 19785 2100 4595 2289 6884 -4784 1 1 X 1 X 1 X 1 1 0 0 428000 428000 0.02070 6581615 4904595 1677020 0.08120 7009615 4904595 2105020 0.10190 46760 46760 0.00230 46760 46760 0.00230 7056375 4904595 2151780 0.10420 1 1529449 764725 5017444 5302390 -284946 X 1 1 1 1 COPPER QUEEN COMMUNITY HOSPITAL

101 COLE AVE BISBEE AZ 85603

X X X X COPPER QUEEN COMMUNITY HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X X X 1 0 1 1 200.000000000000 1 200.000000000000 1 X 1 1 X X 1 X 1 X X X X 1 X 0 0 3 COPPER QUEEN MEDICAL ASSOCIATES-DOUGLAS

100 E 5TH ST DOUGLAS AZ 85607

RURAL HEALTH CLINIC COPPER QUEEN MEDICAL ASSOCIATES-BISBEE

101 COLE AVE BISBEE AZ 85603

RURAL HEALTH CLINIC COPPER QUEEN MEDICAL ASSOCIATES-PALOMINA

10524 HIGHWAY 92 HEREFORD AZ 85615

RURAL HEALTH CLINIC PART I, LINE 7: THE COST ACCOUNTING SYSTEM WAS USED TO REPORT THE SUBSIDIZED HEALTH SERVICES REVENUE AND EXPENSE. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, AND ETC.) PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1790528. PART II: N/A. PART III, LINE 4: FINANCIAL NOTES REGARDING BAD DEBTS, PAGE 11 OF AUDITED FINANCIAL STATEMENTSTHE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, THE AGE OF ACCOUNTS, THE PAYOR MIX, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS.BAD DEBTS ARE MONITORED BY MANAGEMENT AND ARE DETERMINED TO BE DELINQUENT BASED UPON REVIEW OF AGING REPORTS COUPLED WITH CORRESPONDENCE WITH PATIENTS AND THIRD-PARTY PAYORS. BAD DEBTS ARE WRITTEN OFF WHEN ALL REASONABLE ATTEMPTS TO COLLECT THE DEBT HAVE BEEN EXHAUSTED.A COST TO CHARGES RATIO IS USED TO DETERMINE THE BAD DEBT EXPENSE AT COST. SHORTFALL IS NOT INCLUDED AS PART OF COMMUNITY BENEFIT. COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 4: SOUTHEAST ARIZONA MEDICAL CENTERBENSON HOSPITALNORTHERN COCHISE COMMUNITY HOSPITAL COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 5C: THE REPORT IS PROVIDED ON COCHISE COUNTY WEBSITE. COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 6I: THE HOSPITAL HAS INITIATED THREE PROGRAMS TO ADDRESS HEALTH NEEDS IN THE AREA. THE HEALTH NEEDS IN COCHISE COUNTY ARE NUMEROUS AND ANY ONE INDIVIDUAL ORGANIZATION CANNOT POSSIBLY ADDRESS THEM ALL. 1. IN PARTNERSHIP WITH THE COUNTY, THE HOSPITAL HAS ESTABLISHED A HEALTH LIVING PROGRAM THAT TARGETS AT RISK PEOPLE (OVERWEIGHT, HYPERTENSION, DIABETES) TO PROVIDE EDUCATION ON A HEALTHIER LIFESTYLE TO REDUCE THEIR HEALTH RISK. THIS PROGRAM IS BEING OFFERED IN BISBEE AT THE GYM, DOUGLAS AND PALOMINAS AT THE CLINICS.2. IN PARTNERSHIP WITH THE UNIVERSITY OF ARIZONA, COCHISE COMMUNITY COLLEGE AND THE LOCAL SCHOOL DISTRICTS OF DOUGLAS AND BISBEE, THE HOSPITAL IS OFFERING A CONCUSSION PROGRAM FOR THE COMMUNITY COLLEGE AND HIGH SCHOOL ATHLETES TO INCLUDE SCREENINGS AND EDUCATION.3. THE HOSPITAL IS PROVIDING A PROGRAM CALLED "A NATURAL DEATH" TO MOVE AWAY FROM THE HIGH COST OF DYING. IT WOULD REPLACE DNR AS IT IS CURRENTLY. EDUCATION IS PROVIDED AT THE SENIOR CENTERS IN BISBEE AND DOUGLAS AND FOR ALL OF THE HOSPITAL'S PATIENTS WHEN THEY RECEIVE THEIR ADVANCE DIRECTIVES INFORMATION ON ADMISSION. COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 20D: ANY PATIENT THAT DOES NOT HAVE INSURANCE IS AUTOMATICALLY GIVEN A 50% DISCOUNT ON THE COST OF THEIR MEDICAL CARE. IF THE PATIENT MAKES LESS THAN 200% OF THE FEDERAL POVERTY LEVEL THEY WILL RECEIVE AN ADDITIONAL DISCOUNT BEYOND THE INITAL 50%. THE DISCOUNT WILL BE DETERMINED USING A SLIDING FEE SCALE DISCOUNT. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES BASED UPON HISTORICAL SERVICES PROVIDED. PART VI, LINE 3: IT IS DONE UNDER ADMISSION. THE PATIENTS ARE PROVIDED A COPY OF FINANICAL ASSISTANCE POLICY UPON ADMISSION. FINANIAL ASSISTANCE CONTACT INFORMATION IS ALSO POSTED IN THE LOBBY, EMERGENCY ROOM AND OTHER PATIENT AREA. PATIENTS WITH PAST DUE BALANCES ARE SENT A LETTER ADVISING THEM OF THE AVAILABILITY OF ASSISTANCE BEFORE THEY ARE SENT TO COLLECTIONS. PART VI, LINE 4: THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY SERVICES TO RESIDENTS WITHIN BISBEE, ARIZONA COMMUNITY AND ADJACENT AREAS. THE HOSPITAL ALSO OPERATES A HOME HEALTH AGENCY IN THE SAME GEOGRAPHIC AREA AND THREE RURAL HEALTH CLINICS LOCATED IN BISBEE, DOUGLAS AND PALOMINAS, ARIZONA. PART VI, LINE 5: N/A PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 AZ X X X X 0 0 0 0 0 0 0 0 0 JAMES DICKSON 332569 0 0 0 0 0 19824 0 6969 0 359362 0 0 0 JOSE ROMO 333652 0 0 0 0 0 10009 0 6969 0 350630 0 0 0 HEIDI LODGE 286704 0 0 0 0 0 8601 0 6969 0 302274 0 0 0 DANIEL ROE 500599 0 0 0 0 0 15018 0 6969 0 522586 0 0 0 BRUCE CURTIS 341778 0 0 0 0 0 10253 0 6969 0 359000 0 0 0 W PATRICK COGHLAN 200358 0 0 0 0 0 6011 0 6969 0 213338 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE DRAFT OF 990 FORM AND RELATED SCHEDULES ARE SENT TO AND REVIEWED BY BOARD MEMBERS AND MANAGEMENT BEFORE FILING. COMMENTS AND CHANGES ARE COMMUNICATED WITH THE TAX PREPARER AND ADDRESSED ACCORDINGLY. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE COMPENSATION IS SET BY THE BOARD BASED UPON REVIEW OF AN ANNUAL SALARY SURVEY BY THE ARIZONA HOSPITAL ASSOCIATION. THE HOSPITAL ALSO CONTRACTS WITH AN OUTSIDE CONSULTANT WHO ADVISES THE BOARD REGARDING EXECUTIVE COMPENSATION. THE ABOVE MENTIONED PROCESS IS UTILIZED IN SETTING SALARIES OF ALL OF THE EXECUTIVE TEAM AT THE HOSPITAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ALSO AVAILABLE TO THE PUBLIC THROUGH THE STATE UAR REPORT AND THE FEDERAL MEDICARE COST REPORT. OTHER FEES FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 655,786. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 655,786. OTHER: PROGRAM SERVICE EXPENSES 1,044,479. MANAGEMENT AND GENERAL EXPENSES 732,819. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,777,298. FORM 990, PART XII, LINE 2C: THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT OR REVIEW PROCESSES DURING THE YEAR.