Cheyenne County Hospital Association Inc.

“The university of colorado hospital authority currently employs the chief executive officer for sidney regional medical center. Each month, srmc provides the university of colorado hospital authority with data on services provided to the community for comparison data purposes.”

“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 it 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.”

“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.”

“The university of colorado hospital authority 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.”

“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.”

“Jason petik receives compensation from an unrelated organization, the university of colorado hospital authority, which provides management services to sidney regional medical center.”

“Mandy shaw, md and clinton dorwart, md are physicians of sidney regional medical center and are compensated for the medical services they provide. Neither is paid by the hospital for their service on the board of directors.”

“Professional fees - other: program service expenses 2,208,749. Management and general expenses 86,960. Fundraising expenses 0. Total expenses 2,295,709. Contract services - surgery professionals: program service expenses 2,306,402. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,306,402. Contract services - anesthesia professionals: program service expenses 147,774. Management and general expenses 0. Fundraising expenses 0. Total expenses 147,774. Recruiting fees: program service expenses 486,920. Management and general expenses 0. Fundraising expenses 0. Total expenses 486,920. Contract services - radiology professionals: program service expenses 521,067. Management and general expenses 0. Fundraising expenses 0. Total expenses 521,067.”

“Impairment loss on assets -3,709,937.”

“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.”