2024-11-15T18:51:31-06:00 2023-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 691620000 JASON PETIK CEO 3082545825 2024-11-15 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2024-11-08 2023 2024-10-15 13:58:12Z SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 691620000 85970788 0 X WWW.SIDNEYRMC.COM X 1951 NE TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 11 9 507 55 0 0 132484 8475463 68202392 75970350 651266 1004054 140630 162002 69126772 85611869 31250 17200 0 0 36872806 43466926 0 0 0 29468579 34775578 66372635 78259704 2754137 7352165 97113837 107255886 45716460 47958416 51397377 59297470 TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 0 0 56836413 17200 59071701 SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN AND AROUND SIDNEY, NEBRASKA AND THE REGION. IT ALSO OPERATES LONG-TERM CARE FACILITIES AND TWO PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA. 7580686 5789541 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 49 PATIENTS DAILY DURING 2023. SRMC PROVIDED 17,903 RESIDENT DAYS OF CARE FOR IT'S RESIDENTS FROM THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 5049774 11109108 IN 2023, THE HOSPITAL NURSING DEPARTMENT PROVIDED 1,690 PATIENT DAYS OF CARE, INCLUDING GENERAL INPATIENT, ICU PATIENTS AND SWING BED PATIENTS, AND DELIVERED 79 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 4,196 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2023 AND CARED FOR 338 OBSERVATION PATIENTS WHO NEEDED CARE BUT DID NOT QUALIFY FOR INPATIENT SERVICES UNDER CMS RULES. 69466873 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 210 0 1 507 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 X SARA SHOLAR MD PHYSICIAN AT LARGE 40.00 0.00 X 669484 0 48477 JAMES POPOVICH MD CHIEF OF MEDICAL STAFF 39.00 1.00 X 624896 0 50829 WILLIAM PILE CHAIRMAN 4.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 4.00 0.00 X X 0 0 0 KATHY NARJES SECRETARY 4.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 4.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 4.00 1.00 X 0 0 0 NANCI MCCASLIN MEMBER 4.00 1.00 X 0 0 0 CLEM SCHUMACHER MEMBER 4.00 0.00 X 0 0 0 JEFF HELLER MEMBER 4.00 0.00 X 0 0 0 WILLIAM ROBINSON MEMBER 4.00 0.00 X 0 0 0 DWIGHT SMITH MEMBER THRU 8/2024 4.00 0.00 X 0 0 0 KELLY UTLEY CFO 39.00 1.00 X 263484 0 37363 JASON PETIK CEO 40.00 0.00 X 0 0 0 KELLY CASEY MD SURGEON 40.00 0.00 X 749258 0 65579 REBECCA L ALLARD MD PHYSICIAN 40.00 0.00 X 710817 0 58080 ARIEL SORIANO PHYSICIAN 40.00 0.00 X 614660 0 21063 THERESA SIMMONS CRNA 40.00 0.00 X 514624 0 36551 APRIL SMITH MD HOSPITALIST 40.00 0.00 X 492926 0 52441 4640149 0 370383 62 0 1 1 SAMPSON CONSTRUCTION CO INC 5825 SOUTH 14TH ST LINCOLN NE 68512 LTC CONSTRUCTION 5949023 RURAL PARTNERS IN MEDICINE LLC 11880 AIRPORT WAY BROOMFIELD CO 80021 PHYSICIAN SERVICES 2175029 UNIVERSITY OF COLORADO HEALTH 7901 E LOWRY BLVD SUITE 350 DENVER CO 90230 SYSTEM SUPPORT 860342 BYTES COMPUTER & NETWORK 1620 BROADWAY SUITE D SCOTTSBLUFF NE 69361 SYSTEM SUPPORT 855689 MEDICAL SOLUTIONS LLC 1010 N 102ND STREET SUITE 300 OMAHA NE 68114 TEMPORARY STAFFING SUPPORT 781771 24 37400 8174535 263528 8475463 NET PATIENT SERVICE REVENUE 621110 73702081 73702081 340B REVENUE 621110 1371377 1371377 SCHOOL REHAB REVENUE 621110 207031 207031 689861 689861 75970350 986170 986170 376803 358919 17884 17884 17884 CAFETERIA 722514 162002 162002 162002 85611869 75970350 0 1166056 X 17200 17200 1694965 1393974 300991 132900 132900 31505128 28181922 3323206 936156 828874 107282 8907765 8036060 871705 290012 290012 390340 390340 6400 6400 65790 65790 10925083 9549723 1375360 171266 171266 809408 671097 138311 1454619 1296307 158312 1239103 1144754 94349 232787 182228 50559 172019 88306 83713 1150091 1042980 107111 4185347 3903223 282124 1041539 1041539 MEDICAL SUPPLIES 10696225 10695895 330 RECRUITING FEES 821335 799237 22098 MISCELLANEOUS 676868 426415 250453 FOOD PRODUCTS 433879 433879 303479 180621 122858 78259704 69466873 8792831 0 237726 571758 36686593 28386443 10346979 12073997 892692 968288 1874761 2019859 1004107 1048856 84204424 41370419 35961333 42834005 8275298 8617321 649707 1090156 1184641 9645203 97113837 107255886 5620981 9732154 7456924 7000596 28961631 28536399 3676924 2689267 45716460 47958416 X 51397377 59297470 51397377 59297470 97113837 107255886 7352165 547928 0 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 1 7685 7685 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 1947968 2040468 49591121 25306252 24284869 21060699 15186729 5873970 11512136 877438 10634698 42834005 DEFERRED COMPENSATION PLAN 1470668 ERC RECEIVABLE 8174535 9645203 DEFERRED COMPENSATION PLAN LIABILITY 1470668 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 183210 OTHER LIABILITIES 1035389 2689267 X PART X, LINE 2: THE ORGANIZATION ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE ORGANIZATION RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2023 AND 2022, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 0 0 211273 0 211273 0.00270 9144179 6830708 2313471 0.02960 9355452 6830708 2524744 0.03230 70649 75956 0 0.00000 44127 0 44127 0.00060 53010 0 53010 0.00070 167786 75956 97137 0.00130 9523238 6906664 2621881 0.03360 1 1948301 233796 28478012 29026748 -548736 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1000 POLE CREEK CROSSING SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 23 1 1 1 1 X WWW.SIDNEYRMC.COM/REQUIRED-REGULATORY-POSTINGS/ X WWW.PPHD.ORG/PAGES/CHIP.HTML X 1 23 1 WWW.SIDNEYRMC.COM/REQUIRED-REGULATORY-POSTINGS/ 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X X 1 X WWW.SIDNEYRMC.COM/REQUIRED-REGULATORY-POSTINGS/ X WWW.SIDNEYRMC.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X WWW.SIDNEYRMC.COM/REQUIRED-REGULATORY-POSTINGS/ X X X X X X 1 X 0 X X X X X 1 X 0 0 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 5: A MAPP STEERING COMMITTEE WAS FORMED, MADE UP OF REPRESENTATIVES FROM EACH OF THE NINE RURAL NEBRASKA HEALTH NETWORK HOSPITALS (SEE LIST OF MEMBERS IN LINE 6A). COMMITTEE MEMBERS PROVIDE GUIDANCE THROUGHOUT THE MAPP PROCESS AND ARE CHARGED WITH REVIEWING DATA AND PROGRESS ON THE CHOSEN PRIORITY AREAS, USING QUALITY IMPROVEMENT TO MODIFY IMPLEMENTATION PLANS AS NEEDED, AND SHARING RESULTS WITH STAKEHOLDERS. TWO NEW REPRESENTATIVES JOINED THE COMMITTEE: A REPRESENTATIVE FROM THE PANHANDLE PARTNERSHIP, SERVING AS A REPRESENTATIVE OF A VARIETY OF COMMUNITY-BASED ORGANIZATIONS, AND A REPRESENTATIVE FROM THE LOCAL ECONOMIC DEVELOPMENT DISTRICT, PANHANDLE AREA DEVELOPMENT DISTRICT (PADD).THE COMMUNITY HEALTH SURVEY WAS DISTRIBUTED TO PANHANDLE RESIDENTS IN OCTOBER AND NOVEMBER OF 2022 VIA PAPER AND ELECTRONIC SURVEYS. A COPY OF THE SURVEY CAN BE FOUND IN THE REGIONAL CHA. PAPER COPIES OF THE SURVEY WERE DISTRIBUTED BY HOSPITALS AND COMMUNITY-BASED ORGANIZATIONS. THE ELECTRONIC COPY WAS ADMINISTERED USING QUALTRICS AND SHARED ONLINE BY WEBSITE, SOCIAL MEDIA, AND EMAIL BY PPHD, LOCAL HOSPITALS, AND OTHER COMMUNITY ORGANIZATIONS. COUNTS AND PERCENTAGES FROM THE SURVEY RESPONSES WERE CALCULATED USING MICROSOFT EXCEL. THE INFORMATION INCLUDES RESPONSES FROM CHEYENNE COUNTY RESIDENTS AND THOSE WHO INDICATED THAT SIDNEY REGIONAL MEDICAL CENTER WAS THEIR PRIMARY HEALTHCARE FACILITY. 56 PEOPLE WERE CAPTURED IN THIS GROUP. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-REGIONAL WEST GARDEN COUNTY, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-PERKINS COUNTY HEALTH SERVICES, GRANT, NE CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6B: -RURAL NEBRASKA HEALTHCARE NETWORK-PANHANDLE PARTNERSHIP-SCOTTS BLUFF COUNTY HEALTH DEPARTMENT-NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 11: FOCUS AREA 1: BEHAVIORAL HEALTH : IMPROVE ACCESS TO MENTAL HEALTH CARE1. GROW SRMC TELEPSYCH PROGRAM. PARTNER WITH BRYAN HEALTH AND BOYS TOWN TO PROVIDE TELEPSYCH SERVICE FOR COMMUNITY MEMBERS. COLLABORATE WITH REGIONAL HOSPITALS TO GROW TELEPSYCH CAPACITY. MEET WITH SCHOOL MENTAL HEALTH TEAMS TO SHARE RESOURCES.2. GROW SRMC RELATIONSHIPS WITH COMMUNITY SCHOOLS. KRISTEN ROSE, LICENSED PROFESSIONAL MENTAL HEALTH COUNSELOR, GOES TO SCHOOLS IN THE IMMEDIATE AND SURROUNDING AREAS TO PROVIDE COMET TRAINING. QPR TRAINING CONTINUES WITH KRISTEN. THE BEHAVIORAL HEALTH DEPARTMENT HAS RAISED AWARENESS BY ENCOURAGING THE USE OF "MY COMPANION" APP; AN APP THAT GIVES TEENS AN OUTLET TO EXPRESS AND TRACK THEIR EMOTIONS AND CONNECT TO EMERGENCY HOTLINES IF NEEDED, AS WELL AS 988 LIFE LINE CRISIS CENTER. EATING DISORDER EDUCATION AND AWARENESS REMAINS A TOPIC THAT KRISTIN EDUCATES ON AT BHECN BEHAVIORAL HEALTH CONFERENCES. FOCUS AREA 2: IMPROVE QUALITY CHILD CARE1. CREATE DIAPER AND FORMULA PANTRIES. 2. PARTICIPATE IN COMMUNITY CHILD WORKING GROUPS TO GATHER RESOURCES TO SUPPORT THE DEVELOPMENT OF PROGRAMS. SRMC WOULD ASSIST IN DETERMINING A DONATION SITE. SRMC WOULD SUPPORT LOCAL DAYCARES. PROVIDE CPR TRAINING TO DAYCARE PROVIDERS. JEANNE OGDEN AND BROOKE STEFFENS PROVIDE SAFE SITTER CLASSES, SAFE AT HOME AND A SIMILAR PROGRAM FOR GRANDPARENTS WHO CARE FOR CHILDREN. FUTURE PLANS WILL BE DETERMINED TO PARTNER WITH KIDS KORNER FOR POTENTIAL DIAPER/FORMULA PANTRY. FOCUS AREA 3: IMPROVE COMMUNITY EDUCATION ABOUT HEALTH AND RESOURCES1. DEVELOP RELATIONSHIPS WITH COMMUNITY ORGANIZATIONS WITH THE COMMUNITY NAVIGATOR.2. BUILD THE HOSPITAL'S POSITION OF BEING A GOOD SOURCE OF HEALTH INFORMATION FOR THE COMMUNITY. THE COMMUNITY NAVIGATOR WILL ATTEND COMMUNITY MEETINGS WITH OTHER ORGANIZATIONS AND SHARE RESOURCES, PROMOTE HEALTH AWARENESS MONTHS AND SHARE NUTRITIONAL INFORMATION. MALARIE GABEL IS REACHING OUT TO AREA BUSINESSES TO OFFER PRE EMPLOYMENT EXAM OPPORTUNITIES THROUGH COMMUNITY HEALTH. A NEW RELATIONSHIP HAS BEEN ESTABLISHED WITH CLEAN HARBORS IN KIMBALL.OTHER AREA NEEDS THAT ARE NOT BEING ADDRESSED AT THIS TIME DUE TO SRMC NOT HAVING THE RESOURCES TO ADDRESS THESE NEEDS AT THIS TIME INCLUDE:1. NOT ENOUGH OR NO HEALTH INSURANCE2. SUBSTANCE ABUSE3. AFFORDABLE HOUSINGQUARTER 1IN JANUARY KRISTIN ROSE PRESENTED ON MENTAL HEALTH TO THE BHECN AND A STATEWIDE CONFERENCE. THERE WERE 42 ATTENDEES. KRISTIN ALSO TAUGHT A CPR CLASS WITH 4 ATTENDEES. SHE ALSO MADE A PRESENTATION ON EATING DISORDERS WITH 134 ATTENDEES. THE NATIONAL DIABETES PREVENTION PROGRAM STARTED IN JANUARY AND RUNS ALL YEAR. THE MEETINGS WERE ONCE A MONTH WITH 6 ATTENDEES ALTHOUGH THERE IS A DROP OFF DURING THE YEAR. FEBRUARY WAS HEART HEALTH MONTH AND EMPLOYEES PARTICIPATED BY WEARING RED. PATIENTS WERE ENCOURAGED TO SEE THEIR CARDIOLOGISTS FOR SCREENINGS. SRMC ALSO HIRED AN ECHO/VASCULAR TECH AND WHILE WAITING FOR HER DOPPLER TO ARRIVE SHE COMPLETED HER TRAINING. SHE WILL BE COMPLETING ECHO/VASCULAR STUDIES 5 DAYS A WEEK. KRISTIN ROSE CONTINUED HER TRAINING AND ADDED A COMET TRAINING IN FEBRUARY. MARCH WAS COLORECTAL CANCER AWARENESS MONTH AND THE LAB CONTINUED TO OFFER FREE TEST KITS FOR ELIGIBLE PATIENTS. PT RUNS A PARKINSON'S SUPPORT GROUP ONCE A MONTH. DIRECT ACCESS TESTING WAS UTILIZED BY 228 PATIENTS. THERE WERE 26 COVID VACCINES GIVEN BY RHC THIS QUARTER.QUARTER 2 THE NATIONAL DIABETES PREVENTION PROGRAM DROPPED TO EVERY OTHER WEEK AND 4-5 PARTICIPANTS. KRISTIN ROSE GAVE A PRESENTATION TO THE PANHANDLE PUBLIC HEALTH DISTRICT AND 18 ATTENDEES. SRMC WAS UNABLE TO HAVE A SECOND QUARTER BLOOD DRIVE DUE TO A SCHEDULING CONFLICT WITH THE DONOR CENTER IN SCOTTSBLUFF. DURING THE MONTH OF MAY, SRMC HELD A GROUNDBREAKING CEREMONY FOR THE NEW EXTENDED CARE FACILITY. FREE SPORTS PHYSICALS BEGAN IN MAY AND WILL EXTEND THROUGH THE SUMMER. IN JUNE, SRMC TEAMED UP WITH WNCC AND AHEC TO SPONSOR SCRUB CAMP FOR COMMUNITY MEMBERS INTERESTED IN HEALTH CARE. THIS WAS A 2 DAY, FREE EVENT. THERE WERE APPROXIMATELY 15 PARTICIPANTS. KRISTIN ROSE TAUGHT A COMET CLASS WITH 5 ATTENDEES. THERE ARE 61 PATIENTS ENROLLED IN THE CHRONIC CARE PROGRAM. THE DOPPLER HAS ARRIVED FOR THE ECHO TECH, EXPANDING THE CARDIOVASCULAR SERVICES OFFERED BY SRMC. SINCE THE LIFT OF THE COVID STATE OF EMERGENCY, THE COVID BIVALENT BOOSTERS HAVE BEEN POSTPONED TILL FALL. SENIOR SOCIAL HOUR CONTINUES AT BEHAVIORAL HEALTH MEETING ONCE A WEEK FOR 1.5 HOURS WITH 5 PARTICIPANTS. DIRECT ACCESS TESTING WAS UTILIZED BY 273 PATIENTS THIS QUARTER.QUARTER 3 THE DIABETES PREVENTION PROGRAM CONTINUED IN JULY WITH 5 PARTICIPANTS. OUR SUMMER INTERNS FINISHED AT THE END OF THE MONTH. IN AUGUST THE ONCOLOGY DEPARTMENT HELPED RAISE MONEY FOR THE NIGHT OF HOPE AND RAISED ALMOST $1,000. THE PHYSICAL THERAPY DEPARTMENT STARTED GOING BACK TO SCHOOLS AND SPORTING EVENTS ONCE A WEEK WITH SCHOOL BACK IN SESSION. IN SEPTEMBER LTC WAS AWARDED A 5 STAR RATING FOR THE 3RD YEAR IN A ROW. KRISTIN ROSE PRESENTED AN EATING DISORDER EDUCATION TO APPROXIMATELY 50 ATTENDEES AND ALSO PROVIDED COMET TRAINING TO THE COMMUNITY WITH 3 ATTENDEES. SENIOR SOCIAL HOUR CONTINUES AT BEHAVIOR HEALTH ONCE A WEEK WITH APPROXIMATELY 5 PARTICIPANTS. DIRECT ACCESS TESTING HAD 247 PARTICIPANTS THIS QUARTER. PREPARATIONS ARE BEING MADE FOR THE UPCOMING FLU SHOT SEASON AND COVID VACCINES WILL ALSO BE COMING BACK NEXT QUARTER.QUARTER 4 OCTOBER WAS BREAST CANCER AWARENESS MONTH. MANY EFFORTS WERE MADE TO BRING ATTENTION TO BREAST CANCER AND TESTING. DR. SORIANO AND JOY BATT JOINED THE RADIO STATION SEVERAL TIMES TO DISCUSS THE TOPIC AND DEPARTMENTS THROUGHOUT THE HOSPITAL PARTICIPATED IN DECORATING THEIR AREAS IN A BREAST CANCER AWARENESS THEME. A BLOOD DRIVE TOOK PLACE IN OCTOBER WITH 45 UNITS BEING COLLECTED FOR THE PANHANDLE. SRMC HOSTED THE OKTOBERFEST 10K RUN. COMMUNITY HEALTH FLU SHOTS CONTINUED THROUGH THE 4TH QUARTER WITH APPROXIMATELY 200 FLU SHOTS GIVEN TO LOCAL BUSINESSES AND IN PUBLIC LOCATIONS. BLOOD PRESSURE CHECKS AND EDUCATION CONTINUE ON A WEEKLY BASIS AT VARIOUS LOCATIONS. KRISTIN ROSE GAVE A PRESENTATION AT DOANE UNIVERSITY TO 22 ATTENDEES ABOUT BEHAVIORAL HEALTH. PHYSICAL THERAPY CONTINUES TO ATTEND SPORTING EVENTS AND PROVIDES ASSESSMENTS IN THE SCHOOLS ON A REGULAR BASIS THROUGHOUT THE QUARTER. THE NATIONAL DIABETES PREVENTION PROGRAM FINISHED IN NOVEMBER WITH 4 PARTICIPANTS. SIGNUPS OPENED FOR THE 2024 CLASS IN DECEMBER. SRMC HOSTED LOCAL 10TH GRADE STUDENTS TO LEARN ABOUT HEALTH SCIENCE CAREERS. THIS WAS A JOINT EFFORT WITH MORRILL COUNTY EMS. THE SENIOR SOCIAL HOUR GROUP HOSTED THEIR FIRST ART SHOW AND CONTINUE TO MEET WEEKLY WITH APPROXIMATELY 5 PARTICIPANTS. ANOTHER BLOOD DRIVE TOOK PLACE IN DECEMBER WITH 37 UNITS COLLECTED FOR THE PANHANDLE. GUS, THE THERAPY DOG, JOINED THE BEHAVIORAL HEALTH TEAM THIS QUARTER. KRISTIN ROSE HELD A COMET TRAINING IN GRAND ISLAND IN DECEMBER. AT THE END OF DECEMBER SRMC PROMOTED A FREE PARENT EDUCATION PROGRAM FOR PREGNANCY, POSTPARTUM AND BREASTFEEDING. THIS WAS PARTNERED WITH YOMINGO. DIRECT ACCESS TESTING HAD 247 PARTICIPANTS IN THE 4TH QUARTER. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 13H: PATIENTS MAY BE CONSIDERED FOR CHARITY CARE FOR MEDICALLY NECESSARY SERVICES. WHEN IN QUESTION, MEDICALLY NECESSARY SERVICES SHALL BE DETERMINED BY THE EXAMINING PHYSICIAN. PATIENTS MUST BE RESIDENTS OF CHEYENNE OR DEUEL COUNTY AND/OR A 20 MILE RADIUS OF SIDNEY REGIONAL MEDICAL CENTER. THIS MAY BE WAIVED FOR PATIENTS ADMITTED VIA THE EMERGENCY DEPARTMENT OR AT THE DISCRETION OF ADMINISTRATION.SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE AND CLASSIFIED WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENT IS DECEASED WITH NO KNOWN ESTATE OR SPOUSE; PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES; PATIENT IS HOMELESS OR HAS BEEN IDENTIFIED AS BEING WITHOUT RESOURCES BASED ON PREVIOUS ACCOUNT ACTION AND CONTACT WITH THE SRMC STAFF. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING LETTERS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN ADMISSIONS AND WAITING AREAS AT THE HOSPITAL. SIGNAGE IS POSTED IN WAITING AREAS REFERRING PATIENTS TO THE WEBSITE TO VIEW THE POLICY. ADDITIONALLY, THE PLAIN LANGUAGE SUMMARY IS INCLUDED IN ALL DISCHARGE PACKETS WITH REFERENCE TO THE WEBSITE OR FINANCIAL SERVICES TO OBTAIN THE ENTIRE POLICY. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 20E: SRMC ATTEMPTS OTHER NON-EXTRAORDINARY COLLECTION EFFORTS SUCH AS: SUBSEQUENT MONTHLY BILLINGS, COLLECTION LETTERS AND/OR TELEPHONE CALLS CONSTITUTING A GENUINE EFFORT TO HELP OUR PATIENTS TO ARRANGE FOR PAYMENT IF THEY CAN AFFORD IT. DOCUMENTATION OF THESE EFFORTS WILL BE MADE BY NOTATING PATIENT ACCOUNTS AND DOCUMENTING STATEMENTS AND REPORTS OF TELEPHONE CALLS AND PERSONAL CONTACTS. FOR ELECTIVE PROCEDURES, PATIENTS ARE ASKED TO MEET WITH A FINANCIAL COUNSELOR BEFORE THE PROCEDURE TO SET UP PAYMENT ARRANGEMENTS. SRMC DOES OFFER LOANS TO PATIENTS WITH NO COLLATERAL FROM THE PATIENTS. SRMC ALSO SECURES FINANCING FOR THE PATIENTS IF THEY DO NOT QUALIFY FOR CHARITY CARE. SRMC DOES NOT REQUIRE PATIENTS WHO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY TO OBTAIN A LOAN TO PAY THE ACCOUNT. 3 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE 549 KELLER DRIVE SIDNEY NE 69162 LONG TERM CARE FACILITY 2 - SLOAN ESTATES ASSISTED LIVING 2550 CRAIG AVENUE SIDNEY NE 69162 ASSISTED LIVING 3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC 610 GROVER ROAD SUITE 4 SIDNEY NE 69162 WALK IN CLINIC PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE HOSPITAL USES ASSET LEVEL, MEDICAL INDIGENCY, UNDERINSURANCE STATUS AND RESIDENCY TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE AND CLASSIFIED WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENT IS DECEASED WITH NO KNOWN ESTATE OR SPOUSE, PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES, PATIENT IS HOMELESS OR HAS BEEN IDENTIFIED AS BEING WITHOUT RESOURCES BASED ON PREVIOUS ACCOUNT ACTION AND CONTACT WITH STAFF. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS NOT PREPARED IN THE CURRENT YEAR. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CONTRIBUTIONS FOR COMMUNITY BENEFIT, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION DOES NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES FOR THE YEAR. PART III, LINE 2: THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 12% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 12 AND 13 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE RURAL HEALTH CLINICS (RHS) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART SRMC'S MISSION TO PROVIDE THESE SERVICES EVEN IF THE MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: COLLECTION EFFORTS SHALL BE SUSPENDED ONCE A FAP APPLICATION HAS BEEN SUBMITTED AND WILL REMAIN SO UNTIL ELIGIBILITY IS DETERMINED. AN ADDITIONAL 30 DAYS SHALL BE GIVEN IF AN APPLICATION IS INCOMPLETE OR MISSING REQUESTED DOCUMENTATION, IN ORDER TO PROVIDE TIME TO RECTIFY MISSING INFORMATION OR UNTIL ELIGIBILITY CAN BE DETERMINED. PATIENTS HAVE 240 DAYS FROM THE DATE OF THE FIRST POST-DISCHARGE BILLING STATEMENT TO APPLY FOR FAP. IF THEY QUALIFY, THEY CAN'T BE CHARGED MORE THAN AMOUNTS GENERAL BILLED CALCULATION. FOR FAP ELIGIBLE PATIENTS, THIS INCLUDES ACCOUNTS THAT HAVE PREVIOUSLY BEEN SENT TO COLLECTION.SRMC DOES NOT ENGAGE IN EXTRAORDINARY COLLECTION ACTIONS AGAINST AN INDIVIDUAL TO OBTAIN PAYMENT FOR CARE BEFORE MAKING REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS POLICY. REASONABLE EFFORTS BY SRMC INCLUDE WRITTEN NOTIFICATION AT ADMISSIONS ND/OR PRIOR TO COLLECTION EFFORTS WHERE PATIENTS ARE ADVISED OF FINANCIAL ASSISTANCE OPTIONS. IN ADDITION, WRITTEN AND/OR VERBAL COMMUNICATION DURING FINANCIAL ADVISEMENT AND PRE-COLLECTION PROCESS SHALL INCLUDE FINANCIAL ASSISTANCE AS A PAYMENT OPTION, FINANCIAL ASSISTANCE INFOMRAITON IS ALSO INCLUDED IN WRITTEN NOTIFICATION ON BILLING STATEMENTS AND PRE-COLLECTION NOTICES. WHEN A PATIENT IS IDENTIFIED ON A PRE-COLLECTION REPORT, REASONABLE ATTEMPTS SHALL BE MADE TO CONTACT THE PATIENT TO ADVISE THEM OF FINANCIAL ASSISTANCE BEFORE THE ACCOUNT IS TURNED IN FOR COLLECTION. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: THE FINANCIAL ASSISTANCE POLICY IS REFERENCED IN BILLING LETTERS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN ADMISSIONS AND WAITING AREAS AT THE HOSPITAL. SIGNAGE IS POSTED IN WAITING AREAS REFERRING PATIENTS TO THE WEBSITE TO REVIEW THE POLICY. ADDITIONALLY, A PLAIN LANGUAGE SUMMARY IS INCLUDED IN ALL DISCHARGE PACKETS WITH REFERENCE TO THE WEBSITE OR FINANCIAL SERVICES TO OBTAIN THE ENTIRE POLICY. AT THE POINT OF REGISTRATION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES OR REGISTRATION STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH IS UNSUCCESSFUL. SOCIAL SERVICES PERSONNEL AND PATIENT FINANCIAL COUNSELORS MEET WITH PATIENTS INDIVIDUALLY WHEN NEEDED REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. PART VI, LINE 4: MOST OF THE AREA THAT THE HOSPITAL SERVES IS LOCATED IN CHEYENNE COUNTY WHICH HAS A POPULATION OF 9,541 PEOPLE AND IS MOSTLY A RURAL AREA. THE CITIES OF SIDNEY, LODGEPOLE, POTTER, DALTON, GURLEY AND SUNOL ARE LOCATED WITHIN THE COUNTY AND ARE GENERALLY WITHIN APPROXIMATELY 30 MILES FROM THE HOSPITAL. ACCORDING TO THE US CENSUS BUREAU, THE 2023 DEMOGRAPHIC IS APPROXIMATELY 94.4% CAUCASIAN. THE MEDIAN HOUSEHOLD INCOME IN CHEYENNE COUNTY IS $54,038 WITH A POVERTY RATE OF 12.0%. THE PERCENTAGE OF PEOPLE UNDER AGE 65 WHO ARE UNINSURED IS 7.6%. SIDNEY REGIONAL MEDICAL IS THE ONLY HOSPITAL SERVING THIS AREA. PART VI, LINE 5: THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY. IN ADDITION TO THE ACTIVITIES ADDRESSED IN THE CHNA REPORT, THE HOSPITAL SUPPORTED THE CHEYENNE COUNTY FAIR AND THE HEALTH CENTER FOUNDATION GOLF TOURNAMENT IN 2023. THE HOSPITAL ALSO PROVIDES OUTREACH SERVICES TO LOCAL BUSINESSES TO ASSURE FLU SHOTS AND IMMUNIZATIONS ARE UP TO DATE AS WELL AS DOING BLOOD PRESSURE SCREENINGS. SRMC ALSO CONDUCTS DIABETES EDUCATION CLASSES AND PARTICIPATES IN THE NATIONAL DIABETES PREVENTION PROGRAM. SRMC OFFERS IN-HOME FOLLOW UP VISITS TO ANY MOTHERS WITH NEW BABIES NO MATTER WHERE THEY DELIVERED THEIR BABY. SRMC ALSO COLLABORATES WITH THE HIGH SCHOOL TO PROVIDE THERAPY CONSULTATION AFTER SPORTING EVENTS AND IS ON SITE AT SPORTING EVENTS TO PROVIDE MEDICAL HELP IF NECESSARY. THE HOSPITAL CONTINUES TO PROVIDE OB AND DELIVERY SERVICES EVEN THOUGH MANY SMALLER HOSPITALS HAVE DISCONTINUED THIS SERVICE IN THEIR COMMUNITIES. COMMUNITY EDUCATION IS ALSO PROVIDED THROUGH RADIO BROADCASTS EACH WEEK WITH VARYING TOPICS. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. 1 DICKEY AND ASSOCIATES AUCTIONEERS 1616 BIRCH STREET SIDNEY NE 69162 822544780 0 7200 YOUTH LIVESTOCK SPONSORSHIP 0 1 PART I, LINE 2: THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. X X X X 0 0 0 0 0 0 0 0 0 KELLY CASEY MD SURGEON 585043 0 164215 0 0 0 30000 0 35723 0 814981 0 0 0 REBECCA L ALLARD MD PHYSICIAN 685817 0 25000 0 0 0 22500 0 35724 0 769041 0 0 0 SARA SHOLAR MD PHYSICIAN AT LARGE 669484 0 0 0 0 0 15250 0 33371 0 718105 0 0 0 JAMES POPOVICH MD CHIEF OF MEDICAL STAFF 624896 0 0 0 0 0 15250 0 35723 0 675869 0 0 0 ARIEL SORIANO PHYSICIAN 614660 0 0 0 0 0 3565 0 17642 0 635867 0 0 0 THERESA SIMMONS CRNA 513237 0 1387 0 0 0 972 0 35723 0 551319 0 0 0 APRIL SMITH MD HOSPITALIST 492926 0 0 0 0 0 15250 0 37335 0 545511 0 0 0 KELLY UTLEY CFO 239987 0 22705 0 792 0 13629 0 23878 0 300991 0 0 0 SCHEDULE J, PART III: JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY MEDICAL GROUP, AN UNRELATED ENTITY. POUDRE VALLEY MEDICAL GROUP PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE COMPENSATION FOR MR. PETIK. MR. PETIK RECEIVED TOTAL COMPENSATION OF $390,340. MR. PETIK'S COMPENSATION IS REFLECTED IN PART IX, LINE 11A. A THE COUNTY OF DEUEL NEBRASKA 476006452 251476AA5 2014-10-16 10000000 CONSTRUCT HOSPITAL 0 0 0 A 2999405 10000000 10000000 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 A 1 SUSAN PETIK EMPLOYEE OF ORGANIZATION AND SPOUSE OF JASON PETIK, CEO 132900 EMPLOYEE COMPENSATION 1 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE IS MADE UP OF 4 MEMBERS OF THE BOARD. THE EXECUTIVE COMMITTEE HAS THE SAME AUTHORITY TO ACT AS THE FULL BOARD. FORM 990, PART VI, SECTION A, LINE 3 POUDRE VALLEY MEDICAL GROUP CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL THE PUBLIC DISCLOSURE COPY TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY MEDICAL GROUP PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. FORM 990, PART VII, SECTION A, LINE 5: JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY MEDICAL GROUP, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 7,253,034. MANAGEMENT AND GENERAL EXPENSES 1,375,360. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,628,394. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 2,114,634. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,114,634. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 182,055. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 182,055. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. SIDNEY REGIONAL MEDICAL CENTER LONG TERM CARE LLC 1000 POLE CREEK CROSSING SIDNEY NE 69162 883636613 LONG-TERM CARE & ASSISTED LIVING NE 5789541 1557819 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 12C, III-FI N/A 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0