2024-03-04T12:30:47-06:00 2023-06-30 410746749 CLIFTONLARSONALLEN LLP 370 INTERLOCKEN BLVD SUITE 500 BROOMFIELD CO 80021 990 2022-07-01 300975387 IVINSON MEMORIAL HOSPITAL IVIN 3077422141 255 NORTH 30TH STREET LARAMIE WY 82072 DOUG FAUS PRESIDENT & CEO 3077422141 2024-03-01 1 DOUG FAUS XXX-XX-XXXX 1 SARAH HINTZ P00492291 3034668822 2024-02-26 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DOUG FAUS 255 NORTH 30TH STREET LARAMIE WY 82072 183762581 0 X WWW.IVINSONHOSPITAL.ORG X 2017 WY TRUSTED PARTNERS IN WORLD-CLASS HEALTHCARE. 13 12 737 55 0 0 2720575 668080 123931811 139581066 10896165 5798217 1149051 1137674 138697602 147185037 1929829 3750863 0 0 49769437 55094899 0 0 277641 62516613 67862383 114215879 126708145 24481723 20476892 330710233 365736374 21428073 22758603 309282160 342977771 X TRUSTED PARTNERS IN WORLD-CLASS HEALTHCARE. BUILDING TRUST WITH OUR PATIENTS AND WITH EACH OTHER. 0 0 105346662 3750863 140216038 IVINSON MEMORIAL HOSPITAL SERVES THE RESIDENTS OF ALBANY COUNTY, WYOMING AND THE SURROUNDING AREA. LARAMIE IS THE LARGEST CITY IN THE SERVICE AREA WITH A POPULATION OF APPROXIMATELY 32,000. THE SERVICES PROVIDED TO THE COMMUNITY ARE BEHAVIORAL HEALTH (INPATIENT), CARDIAC REHAB, CARDIOPULMONARY, CHAPLAIN, DIALYSIS, DISCHARGE PLANNING / SOCIAL SERVICES, EMERGENCY SERVICES, INFECTION CONTROL, INPATIENT ACUTE CARE, INTENSIVE CARE UNIT, IVINSON MEDICAL GROUP, LAB (ANATOMIC / CLINICAL), NUTRITIONAL COUNSELING, OB/GYN, ONCOLOGY, PEDIATRICS, PHARMACY, RADIATION THERAPY, RADIOLOGY / DIAGNOSTIC IMAGING, RADIOLOGY - MRI, RADIOLOGY - CT, RADIOLOGY - NUCLEAR MEDICINE, RADIOLOGY - MAMMOGRAPHY, REHAB - PHYSICAL / OCCUPATIONAL THERAPY, SLEEP LAB, SPEECH PATHOLOGY - INPATIENT (INCLUDING SWING BEDS)/ OUTPATIENT, SURGERY SERVICES, AND ULTRASOUND.FOR THE YEAR ENDED JUNE 30, 2023, IMH HAD THE FOLLOWING STATISTICS:ADMISSIONS - 1,726EMERGENCY VISITS - 11,987URGENT CARE - 7,533OUTPATIENT VISITS - 84,936CLINIC VISITS - 44,773IMH ALSO PROVIDED $3,750,863 IN CHARITY CARE FOR THE YEAR ENDED JUNE 30, 2023.IN 2022, CHARTIS RECOGNIZED IMH AS A TOP 100 RURAL FACILITY. THE CHARTIS CENTER BASES THEIR TOP 100 LIST ON THE HOSPITAL STRENGTH INDEX, AN ASSESSMENT OF A HOSPITAL'S PERFORMANCE IN INPATIENT/OUTPATIENT MARKET SHARE, QUALITY, OUTCOMES, PATIENT PERSPECTIVE, COST, CHARGE AND FINANCIAL EFFICIENCY. THIS IS THE FIFTH YEAR IN A ROW THAT IMH HAS BEEN RECOGNIZED AS A TOP 100 RURAL FACILITY. IN 2022, IMH ALSO RECEIVED AN A GRADE FROM THE LEAPFROG GROUP. 105346662 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 78 0 1 737 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 12 0 1 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JIM BANDS 3077554603 255 NORTH 30TH STREET LARAMIE WY 82072 DOUG FAUS CEO 40.00 0.00 X X 0 0 0 JOSEPH STEINER CHAIR 3.00 0.00 X X 0 0 0 BRAD JACKSON VICE CHAIR 3.00 0.00 X X 0 0 0 CATIE BALLARD PAST CHAIR 3.00 0.00 X X 0 0 0 GARY CRUM TREASURER 3.00 0.00 X X 0 0 0 DENNIS COOK SECRETARY 3.00 0.00 X X 0 0 0 PAM DUNNUCK MEMBER 2.00 0.00 X 0 0 0 JACKIE GONZALES MEMBER 2.00 0.00 X 0 0 0 PETER GOSAR MEMBER 2.00 0.00 X 0 0 0 STAN GUNSTREAM MD MEMBER 2.00 0.00 X 0 0 0 ROLAND MALDONADO MEMBER 2.00 0.00 X 0 0 0 RICK MELONE MEMBER 2.00 0.00 X 0 0 0 SHARON WEBER MEMBER 2.00 0.00 X 0 0 0 JAMES BANDS CFO 38.00 2.00 X 319104 0 46887 TERRY MOSS COO 40.00 0.00 X 259697 0 34345 NICOLE ROONEY CNO 40.00 0.00 X 235439 0 53306 BURK YOUNG MD PHYSICIAN 40.00 0.00 X 665022 0 16403 JOHN KENNEDY MD PHYSICIAN 40.00 0.00 X 597825 0 55806 ERIC UHLMAN MD PHYSICIAN 40.00 0.00 X 500904 0 26934 JOHN ULLRICH MD PHYSICIAN 40.00 0.00 X 609224 0 57422 PAUL JOHNSON MD PHYSICIAN 40.00 0.00 X 490070 0 16755 3677285 0 307858 67 0 1 0 NCAP IMH LLC 3702 AUTOMATION WAY STE 103 FORT COLLINS CO 80525 ANESTHESIA PROVIDERS 3570722 GH PHIPPS WYOMING LLC 1482 COMMERCE DR UNIT Y LARAMIE WY 82070 CONSTRUCTION 2898282 SUMMIT MEDICAL GROUP LLC 700 CENTRAL EXPRESSWAY S STE 400 ALLEN TX 75035 ED PHYSICIANS 1126352 SYNERGY SURGICALISTS LLC 280 W KAGY BLVD SUITE D 320 BOZEMAN MT 59715 ORTHO PHYSICIANS 1055271 REVENUE ENTERPRISES LLC 3131 S VAUGHN WAY SUITE 500 AURORA CO 80014 ACCOUNTS RECEIVABLE 618713 18 668080 668080 PATIENT SERVICE REVENUES 621110 139581066 139581066 139581066 5714404 5714404 599488 0 599488 599488 599488 36624390 36540577 83813 83813 83813 72451 36967 35484 35484 CAFETERIA 722310 402043 402043 MISCELLANEOUS INCOME 900099 100659 100659 502702 147185037 140216038 0 6300919 X 3750863 3750863 1464973 57749 1407224 41260769 35792393 5220523 247853 1501015 1216575 284440 8116219 6374926 1716216 25077 2751923 2141789 605423 4711 147988 147988 74186 74186 758040 758040 18875221 16603407 2271814 604768 10833 593935 3168052 663051 2505001 2334610 1189944 1144666 1505129 45231 1459898 189052 102619 86433 4764613 4403115 361498 1316341 1316341 MEDICAL SUPPLIES 25377230 25165444 211786 BAD DEBT EXPENSE 7288707 7288707 FOOD 735116 399891 335225 REPAIRS & MAINTENANCE 378147 74424 303723 345183 65701 279482 126708145 105346662 21083842 277641 6155847 7863859 20689159 18798487 7470006 9483950 1892813 1585412 1444582 1446382 108295689 34609353 76445767 73686336 148695864 178961483 33290460 39504836 1856742 -1005 32768993 34406634 330710233 365736374 7961598 9487496 13466475 12898091 0 373016 21428073 22758603 X 247754012 281268899 61528148 61708872 309282160 342977771 330710233 365736374 X 20476892 11954094 1264625 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 0 1 15794 15794 0 PART II-B, LINE 1: IVINSON MEMORIAL HOSPITAL PAYS MEMBERSHIP DUES TO THE WYOMING HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATIONS TO LOBBY ON BEHALF OF THEIR MEMBERS FOR HEALTH-RELATED ISSUES, INCLUDING IVINSON MEMORIAL HOSPITAL. 45159000 6209363 38949637 28267256 4259764 24007492 33956553 24140226 9816327 912880 912880 73686336 REAL ESTATE AND HEDGE FUNDS 39504836 C 39504836 DUE FROM RELATED ORGANIZATION 12053000 BENEFICIAL INTEREST IN FOUNDATION 21980618 RIGHT-OF-USE ASSETS, NET 373016 34406634 OPERATING LEASE LIABILITIES 373016 373016 X 149930640 11954094 1128975 1531092 14614161 135316479 11868558 11868558 147185037 116957487 1128975 988925 2117900 114839587 11868558 11868558 126708145 PART X, LINE 2: THE HOSPITAL IS ORGANIZED AS WYOMING NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE HOSPITAL BELIEVES THAT THEY HAVE APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING THEIR ANNUAL FILING REQUIREMENTS, AND AS SUCH, DO NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 1,264,625. RELATED ORGANIZATION REVENUE 229,500. GIFT SHOP COST OF GOODS SOLD 36,967. PART XI, LINE 4B - OTHER ADJUSTMENTS: ELIMINATING ENTRIES 828,988. PROVISION FOR BAD DEBTS 7,288,707. CHARITY CARE REPORTED AS GRANTS 3,750,863. PART XII, LINE 2D - OTHER ADJUSTMENTS: GIFT SHOP COST OF GOODS SOLD 36,967. RELATED ORGANIZATION EXPENSES 951,958. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 7,288,707. CHARITY CARE REPORTED AS GRANTS 3,750,863. ELIMNATING ENTRIES 828,988. CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENTS 8976896 0 0 0 0 0 0 8976896 0 8976896 0 0 0 0 0 0 PART III ACCOUNTING METHOD: 1 1 X 1 X 1 X 1 1 1 0 0 1778604 1778604 0.01890 8598458 3687086 4911372 0.05210 10377062 3687086 6689976 0.07100 423229 423229 0.00450 423229 423229 0.00450 10800291 3687086 7113205 0.07550 1 7288707 1290101 30039196 99603951 -69564755 X 1 1 1 1 IVINSON MEMORIAL HOSPITAL 255 NORTH 30TH STREET LARAMIE WY 82072 WWW.IVINSONHOSPITAL.ORG 15271 X X X IVINSON MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 0 1 X HTTPS://WWW.IVINSONHOSPITAL.ORG/CHNA X 1 22 1 HTTPS://WWW.IVINSONHOSPITAL.ORG/CHNA 0 1 X 150.000000000000 300.000000000000 X X 1 1 X X X X 1 X WWW.IVINSONHOSPITAL.ORG/FINANCIAL-ASSISTANCE X WWW.IVINSONHOSPITAL.ORG/FINANCIAL-ASSISTANCE X WWW.IVINSONHOSPITAL.ORG/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X 1 X 0 0 IVINSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: IVINSON MEMORIAL HOSPITAL ENGAGED SUPPORT FROM UCHEALTH COMMUNITY HEALTH IMPROVEMENT TO ASSIST WITH THE DEVELOPMENT OF THE CHNA. A MULTI-PHASED APPROACH WAS USED TO IDENTIFY THE TOP HEALTH PRIORITIES FOR FUTURE IMPACT. BETWEEN NOVEMBER 2022 AND APRIL 2023, IVINSON CONDUCTED THE CHNA WHICH PROVIDED AN OPPORTUNITY FOR THE HOSPITAL TO ENGAGE PUBLIC HEALTH EXPERTS, MEDICAL PROVIDERS AND COMMUNITY STAKEHOLDERS IN A FORMAL PROCESS TO ENSURE THAT COMMUNITY BENEFIT PROGRAMS AND RESOURCES ARE FOCUSED ON SIGNIFICANT HEALTH NEEDS IDENTIFIED WITHIN THE COMMUNITY. THE PROCESS INCLUDED:1. A COMPREHENSIVE ANALYSIS OF LOCAL, STATE AND, WHERE AVAILABLE, NATIONAL POPULATION HEALTH INDICATORS.2. REQUISITION OF COMMUNITY INPUT ON LOCAL HEALTH ISSUES THROUGH A PUBLIC MEETING AND A WEB-BASED SURVEY.3. A WEB-BASED SURVEY DISTRIBUTED TO HEALTHCARE PROVIDERS AT IVINSON TO GATHER INPUT ON COMMUNITY HEALTH NEEDS. IVINSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: TO GATHER INPUT ON THE MOST SIGNIFICANT HEALTH ISSUES, IVINSON PROVIDED A WEB-BASED SURVEY TO HEALTHCARE PROVIDERS IN ALBANY COUNTY. IVINSON ALSO HOSTED A PUBLIC MEETING WITH MULTI-SECTOR REPRESENTATION WHERE PARTICIPANTS HAD THE OPPORTUNITY TO RESPOND TO THE SURVEY AND PROVIDE VERBAL FEEDBACK. RESPONDENTS WERE ASKED TO RANK EACH OF THE SIGNIFICANT ISSUES IDENTIFIED ABOVE AND DESCRIBE OTHER HEALTH ISSUES FOR CONSIDERATION. FROM THIS REVIEW, THE MOST SIGNIFICANT ISSUES IDENTIFIED WERE:1. ACCESS TO CARE.2. BEHAVIORAL HEALTH (INCLUDING SUBSTANCE USE DISORDERS AND SUICIDE).3. CHRONIC CONDITIONS.4. MATERNAL HEALTH.5. SOCIAL AND ECONOMIC FACTORS.IVINSON'S SENIOR LEADERSHIP TEAM (SLT) REVIEWED ALL FINDINGS OBTAINED FROM THE ACTIVITIES DESCRIBED PREVIOUSLY TO IDENTIFY HEALTH NEEDS PRIORITIES FOR THE CHNA AND CONSIDERED THE FOLLOWING CRITERIA DURING THE DECISION-MAKING PROCESS:1. SCOPE AND SEVERITY OF THE HEALTH NEED.2. POTENTIAL FOR IVINSON TO IMPACT THE HEALTH NEED.3. ALIGNMENT WITH IVINSON STRATEGIES, AS WELL AS LOCAL, STATE AND NATIONAL OBJECTIVES.4. ECONOMIC FEASIBILITY TO ADDRESS THE HEALTH NEED.IVINSON'S SLT IDENTIFIED THE FOLLOWING HEALTH NEEDS AS PRIORITIES FOR THE 2023-2025 CHNA: SOCIAL AND ECONOMIC FACTORS AND BEHAVIORAL HEALTH SERVICES.IN RESPONSE TO THE COMMUNITY NEEDS, IVINSON ENACTED THE FOLLOWING:WE HAVE BEEN WORKING ON THE BEHAVIORAL HEALTH NEEDS AND SOCIAL AND ECONOMIC FACTORS THAT IMPACT BEHAVIORAL HEALTH OF THE COMMUNITY AS NOTED BELOW:1. WORKING WITH UCH TO USE TELEHEALTH WITH MENTAL HEALTH EXAMINERS AND IMH ER. 2. WORKING WITH ALBANY COUNTY MENTAL HEALTH BOARD, ALBANY COUNTY SHERIFF, LARAMIE POLICE DEPARTMENT, UW POLICE, VOA, UW PSYCHOLOGY DEPARTMENT TO CREATE A MENTAL HEALTH CRISIS RESPONSE TEAM, AND WORKING WITH LAW ENFORCEMENT ON CIT TRAINING (CRISIS INTERVENTION TEAM). THIS HAS REDUCED THE NUMBER OF BEHAVIORAL HEALTH CALLS THAT RESULT IN ER ADMISSION OR ARREST FOR MENTAL HEALTH ISSUES. THIS HAS IMPACTED OVER 500 COMMUNITY MEMBERS. 3. WORKING WITH ALBANY COUNTY ATTORNEY'S ON EMERGENCY DETENTIONS, ALBANY COUNTY MENTAL HEALTH BOARD, ALBANY COUNTY SHERIFF, LARAMIE POLICE DEPARTMENT, UW POLICE, VOA, UW PSYCHOLOGY DEPARTMENT GATEKEEPING PROGRAM THAT HAS IMPACTED 50 INDIVIDUALS. 4. 4-H IVINSON PURCHASED OF ONE BEEF AND TWO PIGS AT A COST OF $15,500.00 FOR FOOD DISTRIBUTION IN ALBANY COUNTY. 5. FOOD DISTRIBUTION TO INTERFAITH AND THE LARAMIE SOUP KITCHEN. 6. PROVIDE 520 POUNDS OF FOOD FROM THE IVINSON KITCHEN TO THE LOCAL FOOD BANKS TO INCREASE ACCESS TO FOOD. 7. IVINSON LEADERSHIPS TEAM FILLS 600 SCHOOL FOOD PACKS. TWENTY FIVE IVINSON STAFF PARTNERED WITH THE SCHOOL DISTRICT AND THE MOOSE LODGE TO PACK THESE 600 BAGS. 8. PARTNER WITH THE ALBANY COUNTY SCHOOL DISTRICT TO PROVIDE WATER BOTTLES TO 500 MIDDLE SCHOOL STUDENTS TO INCREASE AWARENESS OF HOW HYDRATION IMPACTS LEARNING AND PERFORMANCE. 9. PROVIDE FINANCIAL SUPPORT TO PUBLIC ASSISTED TRANSPORTATION SERVICES (PATS) FOR TRANSPORTATION BARRIERS FOR 500 RIDES IN ALBANY COUNTY, WYOMING. THIS IS A DONATION FROM IVINSON OF $14,400.00 FOR THE YEAR. PARTNERSHIP WITH LARAMIE CONNECTIONS, PATS, AND EPPSON CENTER FOR SENIORS. 10. PARTICIPATE IN LOCAL SERVICE CLUBS, ROTARY AND KIWANAS CLUB AS AN IVINSON REPRESENTATIVE IN THESE SERVICE PROGRAMS. 11. PSA DAY, WHICH IS A FREE EVENT FOR ALL MALES IN ALBANY, COUNTY WYOMING WHERE PATIENTS GET THEIR BLOOD DRAWN AND THEIR PROSTATE SPECIFIC ANTIGEN CHECKED. THIS IS A PARTNERSHIP WITH WWAMI (UNIVERSITY OF WYOMING MEDICAL SCHOOL STUDENTS) AND IMH CANCER CENTER STAFF. WWAMI PROVIDED 20 STUDENTS AND IMH CANCER CENTER PROVIDED 7 STAFF. PART I, LINE 3C: TO QUALIFY FOR ASSISTANCE UNDER IVINSON MEMORIAL HOSPITAL'S FINANCIAL ASSISTANCE POLICY, AN INDIVIDUAL MUST BE UNINSURED, UNDERINSURED, INELIGIBLE FOR ANY GOVERNMENT HEALTH CARE BENEFIT PROGRAM, AND UNABLE TO PAY FOR EMERGENCY TREATMENT OR MEDICALLY NECESSARY CARE. THE FOLLOWING FACTORS ARE CONSIDERED IN DETERMINING THE AMOUNT OF FINANCIAL ASSISTANCE GRANTED:1. INDIVIDUAL OR FAMILY INCOME AND NET WORTH;2. EMPLOYMENT STATUS AND EARNING CAPACITY;3. FAMILY SIZE;4. OTHER FINANCIAL OBLIGATIONS; AND5. OTHER SOURCES OF PAYMENT FOR THE SERVICES RENDERED. PART I, LINE 7: THE COMMUNITY BENEFIT EXPENSES WERE CALCULATED USING THE SCHEDULE H INSTRUCTIONS' WORKSHEETS TO CALCULATE A COST-TO-CHARGE RATIO, WHICH WAS THEN APPLIED TO TOTAL EXPENSES. 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 $ 7,288,707. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 3: THE PORTION OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE WAS ESTIMATED USING THE PERCENTAGE OF THE SERVICE AREA IDENTIFIED AS LIVING BELOW THE FEDERAL POVERTY LEVEL BASED ON THE MOST RECENT U.S. CENSUS DATA. ACCORDING TO THE U.S. CENSUS BUREAU, 16.8% OF ALBANY COUNTY RESIDENTS LIVED BELOW THE FEDERAL POVERTY LEVEL AS OF JULY 1, 2023. PART III, LINE 4: SEE THE "PATIENT ACCOUNTS RECEIVABLE" PARAGRAPH ON PAGE 9 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF IVINSON MEMORIAL HOSPITAL'S BAD DEBT EXPENSE. PART III, LINE 8: THE MEDICARE REVENUES AND ALLOWABLE COSTS OF CARE WERE CALCULATED USING THE JUNE 30, 2023 MEDICARE COST REPORT. THE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT SINCE IVINSON MEMORIAL HOSPITAL PROVIDES THESE SERVICES TO THE ELDERLY INDIVIDUALS IN OUR COMMUNITY WHO WOULD LIKELY HAVE DIFFICULTY OBTAINING SUFFICIENT MEDICAL CARE WITHOUT THE MEDICARE PROGRAM. PART III, LINE 9B: IVINSON MEMORIAL HOSPITAL BILLS OUT ANY INSURANCE PRIOR TO BILLING THE PATIENT. THESE BILLS NORMALLY GO OUT WITHIN 7 DAYS OF THE SERVICE DATE. AFTER THE INSURANCE COMPANY HAS PAID ITS SHARE OF THE MEDICAL BILL, THE ACCOUNT IS POSTED FOR PAYMENTS AND ADJUSTMENTS AND THEN THE FIRST BILL IS SUBMITTED TO THE PATIENT. THREE STATEMENT CYCLES (MONTHLY) ARE SENT TO THE GUARANTOR FOR UNPAID ACCOUNTS BEFORE ANY REFERRAL TO AN OUTSIDE COLLECTION AGENCY IS MADE. EACH ACCOUNT IS INDIVIDUALLY REVIEWED PRIOR TO BEING SENT TO COLLECTION. IF THE PATIENT REQUESTS FINANCIAL ASSISTANCE, ALL BILLING/COLLECTION ACTIVITY IS SUSPENDED UNTIL A DETERMINATION IS MADE REGARDING THE PATIENT'S REQUEST FOR ASSISTANCE. EACH REQUEST IS REVIEWED BY THE BUSINESS OFFICE STAFF FOR COMPLETENESS AND QUALIFICATION AND THEN FURTHER REVIEWED BY THE PATIENT FINANCIAL SERVICES DIRECTOR AND CFO. THE PATIENT THEN RECEIVES A CALL AND A LETTER EXPLAINING THE DETERMINATION. PART VI, LINE 2: IN 2016, ALBANY COUNTY HOSPITAL DISTRICT PARTNERED WITH ALBANY COUNTY TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT. THIS DOCUMENT WAS USED TO HELP SET STRATEGY FOR THE HOSPITAL DISTRICT, WHICH WAS TRANSFERRED TO IVINSON MEMORIAL HOSPITAL ON JANUARY 1, 2018. THAT COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED PHYSICIAN AVAILABILITY AS ONE OF THE SIGNIFICANT ISSUES, SO IMH HAS BEEN WORKING TO IMPROVE THIS SINCE 2016. PART VI, LINE 3: IVINSON MEMORIAL HOSPITAL EDUCATES THE PUBLIC ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE THROUGH THE FOLLOWING PROCESSES:1. INFORMATION ON BILLING STATEMENTS AND PATIENT CONSENT FORMS;2. INFORMATION POSTED IN EMERGENCY ROOMS, ADMITTING LOCATIONS, WAITING ROOMS, THE BUSINESS OFFICE, AND OTHER PUBLIC PLACES;3. PUBLICATION ON THE HOSPITAL'S WEBSITE;4. PUBLICATION ON BROCHURES AVAILABLE IN PATIENT ACCESS SITES AND OTHER LOCATIONS IN THE COMMUNITY; AND5. REFERRALS GIVEN TO SPECIFIC PATIENTS BY HOSPITAL STAFF. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA IS ALBANY COUNTY, WYOMING. THE LARGEST CITY IN THE COUNTY IS LARAMIE. THE SECONDARY SERVICE AREA INCLUDES SEVERAL ADDITIONAL COUNTIES IN WYOMING AND PARTS OF NORTHERN COLORADO. PART VI, LINE 6: IVINSON MEMORIAL HOSPITAL AFFILIATED WITH UCH AS THEY PROVIDE IVINSON MEMORIAL HOSPITAL A CEO BUT IVINSON MEMORIAL HOSPITAL IS INDEPENDENT AND IS OPERATED BY A FULLY INDEPENDENT BOARD OF DIRECTORS. 1 CHARITY CARE 481 3750863 0 N/A N/A PART I, LINE 2: CHARITY CARE IS AWARDED BASED ON FINANCIAL NEED AND A SLIDING FEE SCALE. X X X X 0 0 0 0 0 0 0 0 0 BURK YOUNG MD PHYSICIAN 565022 0 100000 0 0 0 0 0 16403 0 681425 0 0 0 JOHN ULLRICH MD PHYSICIAN 505668 0 0 0 103556 0 27000 0 30422 0 666646 0 0 0 JOHN KENNEDY MD PHYSICIAN 597825 0 0 0 0 0 23000 0 32806 0 653631 0 0 0 ERIC UHLMAN MD PHYSICIAN 500904 0 0 0 0 0 12074 0 14860 0 527838 0 0 0 PAUL JOHNSON MD PHYSICIAN 490070 0 0 0 0 0 15939 0 816 0 506825 0 0 0 JAMES BANDS CFO 290256 0 28848 0 0 0 14081 0 32806 0 365991 0 0 0 TERRY MOSS COO 240946 0 18751 0 0 0 1539 0 32806 0 294042 0 0 0 NICOLE ROONEY CNO 215020 0 20419 0 0 0 20500 0 32806 0 288745 0 0 0 FORM 990, PART VI, SECTION A, LINE 1A THE COMMITTEES OF THE BOARD SHALL HAVE AND EXERCISE AUTHORITY OF THE BOARD OF DIRECTORS IN THE MANAGEMENT OF THE CORPORATION. HOWEVER, NO SUCH COMMITTEE SHALL HAVE THE AUTHORITY OF THE BOARD OF DIRECTORS IN REFERENCE TO AUTHORIZING DISTRIBUTIONS, ELECTING, APPOINTING OR REMOVING ANY DIRECTOR, AMENDING THE ARTICLES OF INCORPORATION, AMENDING, ALTERING OR REPEALING THE BYLAWS; APPROVING A PLAN OF MERGER, OR APPROVING A SALE, LEASE, EXCHANGE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE CORPORATION'S PROPERTY, WITH OR WITHOUT GOODWILL, OTHERWISE THAN IN THE USUAL AND REGULAR COURSE OF BUSINESS, OR VOLUNTARILY DISSOLVING OR REVOKING A VOLUNTARY DISSOLUTION OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 3 THE CEO IS PROVIDED THROUGH AN AFFILIATION AGREEMENT WITH UCHEALTH. THE CEO'S COMPENSATION IS REVIEWED AND DETERMINED BY IVINSON MEMORIAL HOSPITAL'S BOARD OF DIRECTORS. THE CEO'S EMPLOYMENT WITH UCHEALTH IS CONTINGENT UPON HIM SERVING AS THE CEO OF IVINSON MEMORIAL HOSPITAL AND THEIR CONTINUED ENGAGEMENT WITH IVINSON MEMORIAL HOSPITAL. DOUG FAUS RECEIVED THE FOLLOWING COMPENSATION IN CALENDAR YEAR 2022 FOR HIS SERVICES AS PRESIDENT & CEO: TAXABLE COMPENSATION: BASE: $421,453 BONUS: $44,406 NONTAXABLE DEFERRED COMPENSATION: $27,833 OTHER NONTAXABLE BENEFITS: $27,833 FORM 990, PART VI, SECTION A, LINE 7B SUBJECT TO ANY CONSENTS OF THE DISTRICT AS REQUIRED UNDER THE LEASE AND IMH'S BYLAWS, THE BOARD OF DIRECTORS SHALL HAVE THE POWER TO ALTER, AMEND, OR REPEAL THE BYLAWS OR ADOPT NEW BYLAWS. HOWEVER, THE BOARD OF DIRECTORS MAY NOT AMEND THE BYLAWS, WITHOUT THE DISTRICT'S PREVIOUS APPROVAL, TO (A) APPOINT THE INITIAL ELECTED DIRECTORS PROVIDED IN SECTION 4.4 OR (B) REMOVE OR MODIFY SECTION 14.7 REGARDING CONFLICTS BETWEEN THE LEASE AND THE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN INDEPENDENT CPA FIRM WITH INFORMATION PROVIDED BY MANAGEMENT. THE 990 WAS REVIEWED IN ITS ENTIRETY BY THE FINANCE COMMITTEE OF THE BOARD PRIOR TO FILING. IN ADDITION, THE ENTIRE BOARD WAS GIVEN THE OPPORTUNITY TO REVIEW PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C IVINSON MEMORIAL HOSPITAL HAS A CONFLICT OF INTEREST POLICY THAT COVERS ALL BOARD MEMBERS, OFFICERS, DIRECTORS, MANAGERS, SUPERVISORS AND HIGHLY COMPENSATED EMPLOYEES. ALL COVERED INDIVIDUALS COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT UPON JOINING IVINSON MEMORIAL HOSPITAL AND ANNUALLY THEREAFTER. ALL COVERED INDIVIDUALS HAVE AN OBLIGATION TO DISCLOSE ALL INTERESTS, ACTIONS OR RELATIONSHIPS THAT CREATE AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST OR THAT COULD CREATE SUCH. AFTER SUCH DISCLOSURE, THE INDIVIDUAL LEAVES THE MEETING WHILE THE BOARD, COMMITTEE OR SUPERVISOR DETERMINES WHETHER A CONFLICT EXISTS. IF A CONFLICT IS DEEMED TO EXIST, THE RELEVANT BODY EVALUATES WHETHER A MORE BENEFICIAL TRANSACTION IS AVAILABLE TO IVINSON MEMORIAL HOSPITAL. IF A MORE BENEFICIAL TRANSACTION IS NOT IDENTIFIED, THE RELEVANT BODY VOTES WHETHER TO ENTER THE TRANSACTION THAT INVOLVES THE CONFLICT OF INTEREST. THE INDIVIDUAL WITH THE CONFLICT DOES NOT PARTICIPATE IN THE VOTE. RECORDS ARE KEPT OF ALL SITUATIONS THAT INVOLVE AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST. IF AN INDIVIDUAL FAILS TO DISCLOSE A CONFLICT OF INTEREST, THE INDIVIDUAL IS GIVEN THE OPPORTUNITY TO EXPLAIN, AFTER WHICH THE RELEVANT BODY DETERMINES APPROPRIATE DISCIPLINARY ACTION, IF ANY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD'S COMPENSATION COMMITTEE REVIEWS THE CEO'S COMPENSATION ANNUALLY. THIS COMMITTEE UTILIZES DATA FROM AN INDEPENDENT COMPENSATION CONSULTANT. THE DATA IS CREATED BASED ON COMPARABLE FACILITIES IN THE GEOGRAPHIC REGION. THE COMMITTEES DECISION IS DOCUMENTED IN THE BOARD MINUTES. THE CEO REVIEWS THE COMPENSATION OF OTHER KEY EMPLOYEES. THE CEO UTILIZES DATA FROM AN INDEPENDENT COMPENSATION CONSULTANT WHO PREPARE THE DATA FROM LIKE-SIZED HOSPITALS WITHIN THE GEOGRAPHIC REGION. THIS INFORMATION IS REVIEWED AND APPROVED BY THE BOARD'S COMPENSATION COMMITTEE ANNUALLY AS WELL. COMPENSATION REVIEWS WERE LAST CONDUCTED IN 2023. FORM 990, PART VI, SECTION C, LINE 19 IVINSON MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FINANCIAL AND OPERATIONAL DATA IS ALSO PROVIDED SEMI-ANNUALLY TO THE ALBANY COUNTY HOSPITAL DISTRICT AND THE ALBANY COUNTY BOARD OF COMMISSIONERS, WHICH PRESENTATION IS OPEN TO THE PUBLIC. FORM 990, PART IX, LINE 11G PURCHASE SERVICES: PROGRAM SERVICE EXPENSES 16,603,407. MANAGEMENT AND GENERAL EXPENSES 2,271,814. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 18,875,221. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 1,264,625. FORM 990, PART XII, LINE 2C: THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. IMH QALICB 255 NORTH 30TH STREET LARAMIE WY 82072 843157045 SUPPORT IVINSON MEMORIAL HOSPITAL WY 501(C)(3) LINE 12B, II IMH 1 MEDICINE BOW TECHNOLOGIES INC 3821 BEECH STREET LARAMIE WY 82072 721620736 INFORMATION SERVICES WY IVINSON MEMORIAL HOSPITAL C 1.00000 0 1 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 IMH QALICB A 599488 FAIR MARKET VALUE