2025-11-14T11:29:23-06:00 2024-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 691620000 JASON PETIK CEO 3082545825 2025-11-13 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2025-11-13 2024 2025-03-06 01:10:19Z SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 691620000 88587675 0 X WWW.SIDNEYRMC.COM X 1951 NE TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 11 9 559 15 0 0 8475463 1008404 75970350 86526851 1004054 722210 162002 231124 85611869 88488589 17200 49500 0 0 43466926 48067499 0 0 0 34775578 39019959 78259704 87136958 7352165 1351631 107255886 121972149 47958416 60805763 59297470 61166386 X TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 1 0 66623985 49500 65705832 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. DURING THE CURRENT YEAR, SRMC ALSO BEGAN PROVIDING GROUND AMBULANCE SERVICES UPON EXIT OF THE FORMER SERVICE PROVIDER. 5180010 5644368 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 48 PATIENTS DAILY DURING 2024. SRMC PROVIDED 17,661 RESIDENT DAYS OF CARE FOR IT'S RESIDENTS FROM THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 4600991 15176651 IN 2024, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,048 PATIENT DAYS OF CARE, INCLUDING GENERAL INPATIENT, ICU PATIENTS AND SWING BED PATIENTS, AND DELIVERED 71 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 4,436 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2024 AND CARED FOR 351 OSERVATION PATIENTS WHO NEEDED CARE BUT DID NOT QUALIFY FOR INPATIENT SERVICES UNDER CMS RULES. 76404986 1 1 0 1 0 0 0 0 0 0 1 0 0 0 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 1 559 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 JAMES POPOVICH MD PHYSICIAN AT LARGE 39.00 1.00 X 667835 0 58579 APRIL SMITH MD CHIEF OF MEDICAL STAFF 40.00 0.00 X 606380 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 KELLY UTLEY CFO 40.00 0.00 X 236322 0 36012 JASON PETIK CEO 40.00 0.00 X 413730 0 0 KELLY CASEY MD SURGEON 40.00 0.00 X 913997 0 51400 REBECCA L ALLARD MD PHYSICIAN 40.00 0.00 X 800348 0 54929 SARA SHOLAR MD PHYSICIAN 40.00 0.00 X 656189 0 50738 ARIEL SORIANO PHYSICIAN 40.00 0.00 X 685555 0 36981 JOSHUA CALDWELL UROLOGIST 40.00 0.00 X 715163 0 23999 5695519 0 363467 80 0 1 1 SAMPSON CONSTRUCTION CO INC 5825 SOUTH 14TH ST LINCOLN NE 68512 LTC CONSTRUCTION 11748674 RURAL PARTNERS IN MEDICINE LLC 11880 AIRPORT WAY BROOMFIELD CO 80021 PHYSICIAN SERVICES 3586199 UNIVERSITY OF COLORADO HEALTH 7901 E LOWRY BLVD SUITE 350 DENVER CO 90230 SYSTEM SUPPORT 2219466 BYTES COMPUTER & NETWORK 1620 BROADWAY SUITE D SCOTTSBLUFF NE 69361 SYSTEM SUPPORT 2191236 FUSION MEDICAL STAFFING LLC PO BOX 30131 OMAHA NE 681031231 TEMPORARY STAFFING SUPPORT 1132540 47 304480 703861 63 1008404 NET PATIENT SERVICE REVENUE 621110 84876287 84876287 340B REVENUE 621110 486298 486298 SCHOOL REHAB REVENUE 621110 168476 168476 995790 995790 86526851 821296 821296 99086 -99086 -99086 -99086 CAFETERIA 722514 231124 231124 231124 88488589 86526851 0 953334 X 49500 49500 1656390 1383911 272479 195586 195586 34719458 30736922 3982536 1002292 899400 102892 8189686 6178371 2011315 2304087 1689555 614532 413730 413730 99344 102 99242 66095 66095 10946963 10511576 435387 281288 262007 19281 3867591 3300216 567375 133610 75109 58501 1074365 957677 116688 1183068 1168289 14779 214516 116023 98493 1253873 1137096 116777 4723791 4399869 323922 1162149 127015 1035134 MEDICAL SUPPLIES 11529000 11529000 RECRUITING FEES 917185 885675 31510 FOOD PRODUCTS 497934 497934 MISCELLANEOUS 306704 47055 259649 348753 257098 91655 87136958 76404986 10731972 0 571758 13029617 28386443 13227112 12073997 25058845 968288 0 2019859 2215907 1048856 1429203 97098786 43056071 42834005 54042715 8617321 9314384 268382 1090156 9645203 3385984 107255886 121972149 9732154 8857214 0 75000 7000596 6532333 28536399 39861190 2689267 5480026 47958416 60805763 X 59297470 61166386 59297470 61166386 107255886 121972149 1351631 517285 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 7999 7999 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 68734086 26351599 42382487 23208434 15686823 7521611 3115798 1017649 2098149 54042715 DEFERRED COMPENSATION PLAN LIABILITY 1575334 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 2066648 OTHER LIABILITIES 1838044 5480026 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, 2024 AND 2023, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 0 0 300610 300610 0.00340 9543728 8815950 727778 0.00840 9844338 8815950 1028388 0.01180 10088776 6828442 3260334 0.03740 51494 51494 0.00060 179516 179516 0.00210 10319786 6828442 3491344 0.04010 20164124 15644392 4519732 0.05190 120 1380 7896 7896 0.00010 29 187 2729 2729 0.00000 149 1567 10625 10625 0.00010 1 1650708 198085 30162882 32189152 -2026270 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: DURING THE LATEST CHNA PROCESS, THE FOLLOWING NEEDS WERE IDENTIFIED:1. MENTAL/BEHAVIORAL HEALTH2. CHILDCARE3. COMMUNITY EDUCATIONOTHER AREA NEEDS THAT ARE NOT BEING ADDRESSED AT THIS TIME DUE TO SRMC NOT HAVING THE RESOURCES TO ADDRESS THESE NEEDS AT THIS TIME:1. NOT ENOUGH OR NO HEALTH INSURANCE2. SUBSTANCE ABUSE3. AFFORDABLE HOUSINGTAKING THE SIGNIFICANT NEEDS IDENTIFIED INTO ACCOUNT, THE FOLLOWING GOALS HAVE BEEN SET TO ADDRESS EACH NEED: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 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.DURING THE YEAR, THE FOLLOWING ACTIONS WERE TAKEN TO ACHIEVE THE GOALS SET ABOVE: QUARTER 1SRMC WAS RECOGNIZED AS A HOSPITAL BREASTFEEDING CHAMPION. THE NATIONAL DIABETES PREVENTION PROGRAM (NDPP) STARTED OVER IN JANUARY. THEY MET ONCE A WEEK WITH 5-10 ATTENDEES EVERY WEEK. SRMC PROMOTED HEART HEALTH MONTH IN FEBRUARY. THE NEBRASKA BEEF COUNCIL PRESENTED TO THE NDPP, CARDIAC REHAB AND PT/OT PATIENTS ON HOW TO CHOOSE THE HEALTHIEST CUTS OF MEAT AND HOW TO PREPARE IT. THE REHAB DEPT WENT TO DIFFERENT SCHOOLS IN THE AREA AND DID ATHLETIC ASSESSMENTS ON 10 DIFFERENT OCCASIONS. RWMC BLOOD CENTER COLLECTED A TOTAL OF 44 UNITS AT THE BLOOD DRIVE. THE SAFE SITTER CLASS WAS OFFERED IN MARCH AND HAD 5 PARTICIPANTS. MARCH WAS COLORECTAL CANCER AWARENESS MONTH. THE MARKETING DEPT. ADVERTISED THE FREE TEST KITS THAT ARE AVAILABLE FOR ELIGIBLE PATIENTS THAT CAN BE PICKED UP AT THE LAB DEPT. THE REHAB DEPT. PUT ON A PARKINSON'S SUPPORT GROUP IN JANUARY. 300 PATIENTS UTILIZED DIRECT ACCESS TESTING. MONTHLY BLOOD PRESSURE CHECKS WERE DONE AT OUR 5 REGULARLY SCHEDULED SITES WITH A TOTAL OF 98 BLOOD PRESSURES TAKEN. MET WITH COMMUNITY OUTREACH COORDINATOR TO SEE ABOUT SCHEDULING ADDITIONAL SITES. KRISTEN ROSE DID BEHAVIORAL HEALTH EDUCATION WITH 40 KIDS AT THE SIDNEY MIDDLE SCHOOL. THE MRI MACHINE UPDATE WAS COMPLETED IN MARCH. KRISTEN PRESENTED ON NATURE AND MENTAL WELLBEING TO 47 PARTICIPANTS. WE HAVE PROVIDED SERVICES TO 8 NEW EMPLOYEES FROM CLEAN HARBORS IN QUARTER 1.QUARTER 2IN APRIL, THE NATIONAL DIABETES PREVENTION PROGRAM DROPPED TO EVERY OTHER WEEK AND CONSISTENTLY HAD 6 PARTICIPANTS. SRMC HAD A BOOTH AT THE SPRING EXPO. VARIOUS DEPARTMENTS TOOK SHIFTS AT THE BOOTH TO OFFER A VARIETY OF INFORMATION AND RESOURCES. LIFE ASSIST DEVICES WERE INSTALLED FOR 9 INDIVIDUALS IN QUARTER 2. SRMC PARTNERED WITH YOMINGO, AN ONLINE PARENTHOOD EDUCATION PROGRAM. SRMC HELPED CELEBRATE NEBRASKA PUBLIC TRANSIT WEEK BY SPONSORING A FREE RIDE FRIDAY ON APRIL 26TH FOR OUR COMMUNITY MEMBERS. A SAFE AT HOME AND SAFE SITTER CLASSES WERE OFFERED BY JEANNE OGDEN AND BROOKE STEFFENS. SUN SAFETY INFORMATION WAS SHARED ON SOCIAL MEDIA. SUNSCREEN WAS PROVIDED TO STAFF MEMBERS. IN JUNE, A FREE MONTHLY BLOOD PRESSURE CLINIC WAS STARTED AT SRMC IN THE COFFEE CURE GIVING US 6 BLOOD PRESSURE CLINIC SITES. A TOTAL OF 179 BLOOD PRESSURES WERE TAKEN IN QUARTER 2. WE HAVE PROVIDED SERVICES TO 5 NEW EMPLOYEES FROM CLEAN HARBORS. RWMC BLOOD CENTER COLLECTED A TOTAL OF 33 UNITS AT THE 2ND BLOOD DRIVE FOR THE YEAR. JEANNE DID A CPR CLASS IN PEETZ FOR KIDS AND COACHES. THERE WERE 16 PARTICIPANTS. THE LAB DEPARTMENT HAD 315 DIRECT ACCESS PATIENTS IN QUARTER 2. KRISTEN HAS 6 ENROLLED IN SENIOR SOCIAL. SHE PROVIDED MENTAL HEALTH EDUCATION TO 5 PEOPLE AT THE BHECN PANHANDLE. QUARTER 3 IN JULY, THE NATIONAL DIABETES PREVENTION PROGRAM DROPPED TO ONCE A MONTH AND CONTINUES TO HAVE 4-8 PARTICIPANTS. KRISTEN PROVIDED STRESS MANAGEMENT EDUCATION TO WOMEN IN AG IN SIDNEY WHERE 50 INDIVIDUALS WERE PRESENT AND DID PTSD EDUCATION FOR PLAINSWEST CASA WITH 8 PARTICIPANTS. IN JULY, WE ADDED A 7TH BLOOD PRESSURE CLINIC SITE IN DALTON. A TOTAL OF 261 BLOOD PRESSURES WERE TAKEN IN QUARTER 3. LIFE ASSIST DEVICES WERE INSTALLED FOR 10 INDIVIDUALS IN QUARTER 3. WE HAVE PROVIDED SERVICES TO 13 NEW CLEAN HARBORS EMPLOYEES. RWMC BLOOD CENTER COLLECTED A TOTAL OF 29 UNITS AT THE 3RD BLOOD DRIVE FOR THE YEAR. THE LAB DEPARTMENT HAD 288 DIRECT ACCESS PATIENTS IN THE 3RD QUARTER. KRISTEN PUT ON TWO COMET COMMUNITY TRAININGS AT THE WESTERN NEBRASKA SCHOOL MENTAL HEALTH CONFERENCE. SHE HAD A TOTAL OF 14 PARTICIPANTS. PT ATTENDED 11 SPORTING EVENTS. KRISTEN TRAVELED TO DOANE TO DO MH EDUCATION WITH 14 INDIVIDUALS. THE REHAB DEPT. HELD 2 PARKINSONS SUPPORT GROUP SESSIONS.QUARTER 4 JAMIE PUT ON A SCRUB CAMP IN OCTOBER. COMMUNITY HEALTH ORGANIZED AN EMERGENCY SHORTAGE BLOOD DRIVE IN OCTOBER. MALARIE PARTNERED WITH PRICE CREAM TO GIVE A PINT OF ICE CREAM FOR EVERY DONOR WHO GIVES A PINT OF BLOOD. IN ADDITION TO THE REGULARLY SCHEDULED BLOOD DRIVE IN DECEMBER, THE BLOOD CENTER COLLECTED A TOTAL OF 97 UNITS FOR THE 4TH QUARTER. THE NATIONAL DIABETES PREVENTION PROGRAM CONTINUED TO MEET MONTHLY . THE PROGRAM ENDED ON DECEMBER 4TH WITH 5 PARTICIPANTS SUCCESSFULLY COMPLETING THE PROGRAM. A TOTAL OF 254 ONSITE BLOOD PRESSURES WERE TAKEN IN QUARTER 4. LIFE ASSIST DEVICES WERE INSTALLED FOR 6 INDIVIDUALS. WE PROVIDED SERVICES TO 6 NEW EMPLOYEES FOR CLEAN HARBORS. THE LAB DEPARTMENT HAD 288 DIRECT ACCESS PATIENTS IN THE 4TH QUARTER. KRISTEN HELD A MATERNAL MH EDUCATION CLASS FOR SIDNEY/MIERA MOON COLLECTIVE WITH 6 PARTICIPANTS. PT ATTENDED 3 SPORTING EVENTS. COMMUNITY HEALTH ORGANIZED A DIAPER DRIVE IN DECEMBER AND HAD 30 FAMILIES RECEIVE DIAPERS, WIPES, AND/OR FORMULA. 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. 4 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE 1855 GREENWOOD ROAD 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 GLOVER ROAD SUITE 4 SIDNEY NE 69162 WALK IN CLINIC 4 - SIDNEY REGIONAL MEDICAL CENTER EMS 1000 POLE CREEK CROSSING SIDNEY NE 69162 EMS AMBULANCE SERVICES 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 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: COMMUNITY BUILDING ACTIVITIES INCLUDE THERAPISTS AVAILABLE AT SPORTING EVENTS AND COMMUNITY CENTERS, AS WELL AS WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. OTHER ACTIVITIES INCLUDE BLOOD DRAWS, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS AND RESIDENTS. 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 13 AND 14 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. 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: 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 COMMUNITY THROUGH ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT SPORTING EVENTS AND THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. OTHER ACTIVITIES INCLUDE COMMUNITY BLOOD DRAWS, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. 1 DICKEY AND ASSOCIATES AUCTIONEERS 1616 BIRCH STREET SIDNEY NE 69162 822544780 8500 0 YOUTH LIVESTOCK SPONSORSHIP THE CATTLEMAN'S BALL 4834 ROAD T DAVENPORT NE 68335 911812186 501(C)(3) 21000 0 ANNUAL DONATION SIDNEY HIGH SCHOOLS 1101 21ST AVE SIDNEY NE 69162 476001927 GOVERNMENTAL ENTITY 10000 0 SIDNEY HS PARTNERSHIP AGREEMENT 2 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 1 1 X X X 0 0 0 0 0 0 0 0 0 KELLY CASEY MD SURGEON 629966 0 284031 0 0 0 14453 0 37097 0 965547 0 0 0 REBECCA L ALLARD MD PHYSICIAN 800348 0 0 0 0 0 15250 0 39823 0 855421 0 0 0 JOSHUA CALDWELL UROLOGIST 539407 0 175756 0 0 0 15250 0 8876 0 739289 0 0 0 JAMES POPOVICH MD PHYSICIAN AT LARGE 637835 0 30000 0 0 0 23000 0 35723 0 726558 0 0 0 ARIEL SORIANO PHYSICIAN 640555 0 45000 0 0 0 19483 0 17642 0 722680 0 0 0 SARA SHOLAR MD PHYSICIAN 626189 0 30000 0 0 0 15250 0 35632 0 707071 0 0 0 APRIL SMITH MD CHIEF OF MEDICAL STAFF 556380 0 50000 0 0 0 15250 0 35723 0 657353 0 0 0 JASON PETIK CEO 413730 0 0 0 0 0 0 0 0 0 413730 0 0 0 KELLY UTLEY CFO 235530 0 0 0 792 0 12278 0 23878 0 272478 0 0 0 PART I, LINE 1A CHARTER AIRFAIRE, WHICH WAS ONLY FOR BUSINESS TRAVEL AND REIMBURSED UNDER AN ACCOUNTABLE PLAN, AND PAID HOUSING, PROVIDED BY THE HOSPITAL AND REQUIRED AS A CONDITION OF EMPLOYMENT FOR THE EMPLOYER'S CONVENIENCE, WAS PROVIDED FOR AERIEL SORIANO, PHYSICIAN, AND WAS NOT INCLUDED IN TAXABLE INCOME. 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 $413,730. 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 3467667 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 147285 EMPLOYEE COMPENSATION 0 KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 48302 EMPLOYEE COMPENSATION 0 FORM 990, PART III, LINE 2 DURING THE YEAR, THE HOSPITAL BEGAN PROVIDING GROUND AMBULANCE SERVICES UPON EXIT OF THE FORMER SERVICE PROVIDER. 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 8,281,909. MANAGEMENT AND GENERAL EXPENSES 435,387. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,717,296. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 1,702,160. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,702,160. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 527,507. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 527,507. 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 6091185 3120780 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC SIDNEY REGIONAL MEDICAL CENTER EMS LLC 1000 POLE CREEK CROSSING SIDNEY NE 69162 993681050 EMERGENCY MEDICAL SERVICES NE 325269 277718 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