Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2010 and ending 06-30-2011
BCheck if applicable:
CName of organization
NORTHERN MONTANA HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
PO BOX 1231
 
Room/suite
City or town, state or country, and ZIP + 4
HAVRE, MT595011231
D Employer identification number

81-0231787
E Telephone number

G Gross receipts $ 67,986,721
F Name and address of principal officer:
DAVID HENRY
PO BOX 1231
HAVRE,MT595011231
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.NMHCARE.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1921
M State of legal domicile: MT
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: PROVISION OF HEALTHCARE SERVICES.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 12
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 7
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 762
6 Total number of volunteers (estimate if necessary) .... 6 115
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 431,496
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 371,041 237,879
9 Program service revenue (Part VIII, line 2g) ......... 52,416,962 52,974,508
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 452,871 922,805
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 12,056 11,540
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 53,252,930 54,146,732
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 8,909 9,152
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 28,161,270 28,598,427
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 23,362,441 22,385,565
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 51,532,620 50,993,144
19 Revenue less expenses. Subtract line 18 from line 12...... 1,720,310 3,153,588
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 50,643,440 53,915,880
21 Total liabilities (Part X, line 26)............ 11,345,455 9,021,711
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 39,297,985 44,894,169
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: TO DELIVER HIGH QUALITY COMPREHENSIVE HEALTH CARE SERVICES TO THE HI-LINE COMMUNITIES.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 38,146,336 including grants of $   ) (Revenue $ 52,543,012 )
NORTHERN MONTANA HOSPITAL (HOSPITAL) PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION TO ALL COMMUNITY MEMBERS. DURING THE YEAR ENDED JUNE 30, 2011, THE HOSPITAL PROVIDED $1,262,053 OF MEDICAL SERVICES, BASED ON CHARGES, TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE OF PROVIDING CARE TO THESE PATIENTS WAS $27,645,331 FOR THE YEAR ENDED JUNE 30, 2011. DURING THE FISCAL YEAR ENDED JUNE 30, 2011 THE HOSPITAL PROVIDED OVER 5,000 DAYS OF HOSPITAL SERVICES. THE NURSING HOME PROVIDED OVER 39,000 DAYS OF RESIDENT SERVICES DURING THE YEAR.THE HOSPITAL ALSO PROVIDES COMMUNITY CARE AND SERVICES THROUGH MANY HEALTH CARE ACTIVITIES AND PROGRAMS PROVIDED TO SUPPORT THE COMMUNITY. THESE ACTIVITIES INCLUDE: WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SENIOR SERVICES, HEALTH CARE SCREENING, SPECIAL PROGRAMS FOR SPECIFIC GROUPS, PUBLISHED ARTICLES, RADIO PROGRAMS, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. THE HOSPITAL ALSO RECEIVED MANY HOURS OF VOLUNTEER HELP FROM THE COMMUNITY RESIDENTS.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 38,146,336
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
Yes
 
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II...........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III...............
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
 
No
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
103
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
762
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
12
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
7
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
 
No
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
 
No
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
KIM LUCKE VP OF FINANCE
PO BOX 1231
HAVRE,MT59501
(406) 265-2211
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) DAVID C HENRY
PRESIDENT/CEO
 40.00 X   X       347,250 0 0
(2) DAVID LEEDS
TREASURER
 1.00 X   X       0 0 0
(3) JUDY GREENWOOD
SECRETARY
 1.00 X   X       0 0 0
(4) MILES HAMILTON
CHAIRMAN
 1.00 X   X       0 0 0
(5) BRUCE RICHARDSON MD
VICE-CHAIRMAN
 40.00 X   X       322,727 0 18,229
(6) PAUL TUSS
TRUSTEE
 1.00 X           0 0 0
(7) STEPHEN BECHDOLT MD
TRUSTEE
 40.00 X           277,266 0 11,019
(8) TOM PATRICK
TRUSTEE
 1.00 X           0 0 0
(9) ANDREW CARLSON
TRUSTEE
 1.00 X           0 0 0
(10) MARGARET DOW MD
TRUSTEE - IPD MEMBER
 40.00 X           206,109 0 22,828
(11) MICHAEL NOLAN MD
TRUSTEE - IPD MEMBER
 40.00 X           256,158 0 3,048
(12) JULIE HOLT
TRUSTEE
 1.00 X           0 0 0
(13) KAREN POLLINGTON
VICE PRESIDENT
 40.00     X       91,011 0 18,417
(14) KIM LUCKE
VP OF FINANCE
 40.00     X       70,551 0 15,318
(15) JOEL CLEARY MD
DOCTOR
 40.00         X   345,808 0 1,386
(16) KAREN E LIEN MD
DOCTOR
 40.00         X   319,656 0 20,779
(17) JOHN TRUE MD
DOCTOR
 40.00         X   352,286 0 0
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) SHAHRIAR ANOUSHFAR MD
DOCTOR
 40.00         X   374,225 0 7,844
(19) SUZANNE SWIETNICKI MD
DOCTOR
 40.00         X   243,861 0 21,321






















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,206,908 0 140,189
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet34
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
MARK A WARD DO
120 W 30TH STREET
HAVRE,MT59501 		CONTRACT PHYSICIAN SERVICES 360,926
MERIDIAN MEDICAL STAFFING
26 W DRYCREEK CIRCLE SUITE 600
LITTLETON,CO80120 		NURSING STAFFING 329,209
DANIEL ABBOTT
1715 13TH STREET WEST
HAVRE,MT59501 		ANESTHESIA SERVICES 327,482
PHILIPS MEDICAL SYSTEMS
22100 BOTHELL EVERETT HIGHWAY
BOTHELL,WA98041 		MAINTENANCE SERVICES 281,077
LISTON RADIOLOGY CONSULTING
1562 RIALTO LANE
DAVIS,CA95618 		CONTRACT RADIOLOGY SERVICES 240,142
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet13
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 185,110
e Government grants (contributions)1e 19,600
f All other contributions, gifts, grants, and
similar amounts not included above1f 		33,169
g Noncash contributions included in lines 1a-1f:$ 10,110
h Total. Add lines 1a-1f.......MediumBullet 237,879
Program Service Revenue Business Code
2a NET PATIENT SERVICE RE 622,110 46,076,753 46,076,753    
b PHARMACY 446,110 6,150,287 5,718,791 431,496  
c HEALTHCARE CONSULTING 541,900 418,151 418,151    
d CAFETERIA REVENUE 722,210 232,285 232,285    
e OTHER PROGRAM REVENUE 900,099 97,032 97,032    
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 52,974,508
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 786,666     786,666
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross Rents 11,040 500
b Less: rental expenses    
c Rental income or (loss) 11,040 500
d Net rental income or (loss).......MediumBullet 11,540     11,540
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 13,915,824 60,304
b Less: cost or other basis and sales expenses 13,813,934 26,055
c Gain or (loss) 101,890 34,249
d Net gain or (loss)..........MediumBullet 136,139     136,139
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet  
12 Total revenue. See Instructions....MediumBullet 54,146,732 52,543,012 431,496 934,345
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21    
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 9,152 9,152
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 1,934,630 1,348,827 585,803  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 22,256,367 15,579,457 6,676,910  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 865,492 564,871 300,621  
9 Other employee benefits ....... 1,541,966 910,775 631,191  
10 Payroll taxes ........... 1,999,972 1,399,980 599,992  
11 Fees for services (non-employees):        
a Management ...... 291,000 58,200 232,800  
b Legal ......... 35,938   35,938  
c Accounting ........... 70,364   70,364  
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 4,661,347 4,385,316 276,031  
12 Advertising and promotion .... 342,434   342,434  
13 Office expenses ....... 6,931,881 5,892,099 1,039,782  
14 Information technology ...... 428,241 342,593 85,648  
15 Royalties ..        
16 Occupancy ........... 1,749,351 1,224,546 524,805  
17 Travel ............ 214,903 75,216 139,687  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ........... 103   103  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 1,845,555 1,291,889 553,666  
23 Insurance .............. 1,324,169 1,059,335 264,834  
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a BAD DEBT EXPENSE 2,903,633 2,903,633    
b EQUIPMENT RENTAL AND MA 843,180 463,749 379,431  
c BED TAX 610,006 610,006    
d
e
f All other expenses 133,460 26,692 106,768  
25 Total functional expenses. Add lines 1 through 24f 50,993,144 38,146,336 12,846,808 0
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 4,475,278 1 5,390,345
2 Savings and temporary cash investments ....... 936,844 2 287,849
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 10,620,214 4 11,385,437
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 1,378,066 8 1,319,273
9 Prepaid expenses and deferred charges ............ 391,380 9 713,310
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 46,181,805
b Less: accumulated depreciation. ..... 10b 37,552,627 9,073,946 10c 8,629,178
11 Investments—publicly traded securities .......... 20,135,368 11 25,350,329
12 Investments—other securities. See Part IV, line 11 ...... 3,327,184 12 90,226
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 305,160 15 749,933
16 Total assets. Add lines 1 through 15 (must equal line 34)... 50,643,440 16 53,915,880
Liabilities 17 Accounts payable and accrued expenses . 4,392,924 17 3,759,420
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 6,952,531 25 5,262,291
26 Total liabilities. Add lines 17 through 25..... 11,345,455 26 9,021,711
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 39,297,985 27 44,894,169
28 Temporarily restricted net assets .....   28  
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 39,297,985 33 44,894,169
34 Total liabilities and net assets/fund balances ..... 50,643,440 34 53,915,880
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
54,146,732
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
50,993,144
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
3,153,588
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
39,297,985
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
2,442,596
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
44,894,169
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
 
No
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
NORTHERN MONTANA HOSPITAL
  		Employer identification number

81-0231787
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
NORTHERN MONTANA HOSPITAL
  		Employer identification number

81-0231787
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
NORTHERN MONTANA HOSPITAL
  		Employer identification number

81-0231787
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c 30,662
d Additions during the year .............................. 1d 104,037
e Distributions during the year ............................. 1e 102,290
f Ending balance ................................... 1f 32,409
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   75,272 75,272
b Buildings ................   19,732,336 15,819,824 3,912,512
c Leasehold improvements ............        
d Equipment ................   25,159,741 21,052,301 4,107,440
e Other .................   1,214,456 680,502 533,954
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 8,629,178
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes  
LIABILITY FOR PENSION BENEFITS 4,499,593
THIRD-PARTY PAYOR SETTLEMENTS 762,698







Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 5,262,291
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
  PART IV, LINE 1B: PART IV, LINE 1B: THE CUSTODIAL FUNDS ARE NOT REPORTED ON THE BALANCE SHEET OF NMH AS THEY ARE THE PERSONAL RESOURCE FUNDS OF THE RESIDENTS TO BE USED ONLY FOR THEIR PERSONAL NEEDS. IF THE RESIDENT PASSES, THE FUNDS EITHER GO TO THE FAMILY OR BACK TO THE STATE. THEY ARE IN NO WAY AN ASSET OF THE ORGANIZATION.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: PART X, LINE 2: THE ORGANIZATION UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES. AS OF JUNE 30, 2011 AND 2010, THE UNRECOGNIZED TAX BENEFIT ACCRUAL IS ZERO.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
 
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		    734,257   734,257 1.530 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    10,991,865 10,127,417 864,448 1.800 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....     238,133 266,297 -28,164 0 %
dTotal Charity Care and
Means-Tested Government Programs ..... 		    11,964,255 10,393,714 1,570,541 3.330 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		  12,667 7,728   7,728 0.020 %
f Health professions education
(from Worksheet 5) .. 		  160 20,532   20,532 0.040 %
g Subsidized health services
(from Worksheet 6) .. 		  10,335 7,944,322 6,358,942 1,585,380 3.300 %
h Research (from Worksheet 7)   0        
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		  3,626 23,226   23,226 0.050 %
jTotal Other Benefits ...   26,788 7,995,808 6,358,942 1,636,866 3.410 %
kTotal. Add lines 7d and 7j. ..   26,788 19,960,063 16,752,656 3,207,407 6.740 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing   3,780 7,427   7,427 0.020 %
2 Economic development            
3 Community support   163 1,796   1,796 0 %
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building   1,342 861   861 0 %
7 Community health improvement advocacy            
8 Workforce development            
9 Other   44 1,950   1,950 0 %
10 Total   5,329 12,034   12,034 0.020 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense (at cost).....
2
1,689,321
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
26,327
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
8,963,871
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
9,206,903
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-243,032
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
 
No
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
 
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 NORTHERN MONTANA HOSPITAL
30 13TH STREET
HAVRE,MT59501 		X X         X    
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:NA
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?3
Name and address Type of Facility (Describe)
1 NORTHERN MONTANA MEDICAL GROUP WEST
20 13TH STREET WEST
HAVRE,MT59501 		CLINIC
2 NORTHERN MONTANA MEDICAL GROUP WEST
20 13TH STREET WEST
HAVRE,MT59501 		CLINIC
3 NORTHERN MONTANA MEDICAL GROUP WEST
20 13TH STREET WEST
HAVRE,MT59501 		CLINIC
4
5
6
7
8
9
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
    PART I, LINE 6A: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT WAS PUBLISHED AS A 1/2 PAGE AD IN THE LOCAL NEWSPAPER. IN ADDITION, A STATEMENT ABOUT THE AMOUNT OF COMMUNITY BENEFIT THE ORGANIZATION PROVIDED CAN BE FOUND ON OUR WEB-SITE AT WWW.NMHCARE.ORG.
    PART I, LINE 7: CHARITY CARE EXPENSE ON LINE 7A WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. UNREIMBURSED MEDICAID, LINE 7B, AND UNREIMBURSED COSTS - OTHER MEANS-TESTED GOVERNMENT PROGRAMS, LINE 7C, WERE CALCULATED USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CASH AND IN-KIND DONATIONS, LINE 7I, ARE ACTUAL COSTS REPORTED IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2.
    PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION WAS $2,903,633.
    PART II: REPORTED UNDER COMMUNITY BUILDING ACTIVITIES IS THE MAINTENANCE OF OUR FITNESS PARK. IT IS A 7 ACRE PARK WITH CONCRETE WALKING TRAILS, A SOFTBALL AND SOCCER FIELD AND IS A PLACE FOR THE COMMUNITY TO GET OUTDOORS AND EXERCISE. ALSO INCLUDED IS STORAGE OF BASKETBALL HOOPS FOR THE 3-ON-3 TOURNAMENTS THE CITY PUTS ON TO GET YOUTH OUT AND ACTIVE. MANY LEADERS OF THE ORGANIZATION SERVE ON VARIOUS BOARDS THROUGHOUT THE COMMUNITY, SUCH AS THE CHAMBER OF COMMERCE, HILL COUNTY PLANNING BOARD AND HILL COUNTY HEALTH CONSORTIUM. THROUGH THESE SERVICES, WE ARE ABLE TO KEEP ABREAST OF HEALTHCARE NEEDS IN THE COMMUNITY AND COLLABORATE WITH VARIOUS ORGANIZATIONS TO HELP MAKE IT HAPPEN.
    PART III, LINE 4: BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2.THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BY USING CHARITY CARE AS A PERCENTAGE OF GROSS PATIENT SERVICE REVENUE. AS A PORTION OF REVENUE IS CONSIDERED CHARITY CARE, IT IS ASSUMED THAT A PERCENTAGE OF BAD DEBT EXPENSE WOULD ALSO BE CONSIDERED CHARITY CARE.BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION.
    PART III, LINE 8: THESE EXPENSES REPRESENT AN OVERALL SHORTFALL OF THE MEDICARE PATIENT POPULATION. THE COSTS THEMSELVES ARE THEREFORE A COMMUNITY BENEFIT AS THE COMMUNITY WOULD NOT RECEIVE THESE SERVICES IF WE DID NOT PROVIDE THEM. MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS.
    PART III, LINE 9B: THE ORGANIZATION DOES NOT HAVE A WRITTEN DEBT COLLECTION POLICY, BUT HAVE WRITTEN PROCEDURES THAT THEY FOLLOW. THE ORGANIZATION IS WORKING ON DEVELOPING A WRITTEN DEBT COLLECTION POLICY. THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY PROVIDES HOW THEY WILL COLLECT FROM THOSE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. THE POLICY STATES "DURING THE PATIENT REGISTRATION OR COLLECTION PROCESS, THE HOSPITAL WILL MAKE AN INITIAL DETERMINATION OF ELIGIBILITY BASED ON VERBAL OR WRITTEN APPLICATION FOR CHARITY CARE. PENDING FINAL ELIGIBILITY DETERMINATION, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS, PROVIDED THAT THE RESPONSIBLE PARTY IS COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF STATUS, INCLUDING RETURN OF APPLICATIONS AND DOCUMENTATION REQUIRED BY THE HOSPITAL WITHIN FOURTEEN (14) DAYS OF RECEIPT."
    PART VI, LINE 2: COMMUNITY NEEDS ASSESSMENTS ARE CONDUCTED THROUGHOUT THE COMMUNITY BY ORGANIZATIONS SUCH AS HRDC, THE BOYS & GIRLS CLUB AND THE MONTANA ECONOMIC DEVELOPMENT COUNCIL. THESE ASSESSMENTS ARE SHARED WITH THE COMMUNITY. THROUGH THESE ASSESSMENTS, NORTHERN MONTANA HOSPITAL IS ABLE TO IDENTIFY THE NEEDS WE CAN HELP MEET. THE CURRENT NEEDS ARE: TRANSPORTATION, MENTAL HEALTH AND YOUTH IN NEED. NORTHERN MONTANA HOSPITAL HAS KEY EMPLOYEES THAT ARE WORKING WITH A COLLECTIVE COMMUNITY GROUP ON THE TRANSPORTATION COALITION. WE ALSO PARTICIPATE IN A COMMUNITY PROGRAM, 'HEALTHY YOUTH, HEALTHY COMMUNITY' IN COALITION WITH THE BOYS & GIRLS CLUB AND OTHER COMMUNITY ORGANIZATIONS. NORTHERN MONTANA HOSPITAL IS HELPING TO MEET THE MENTAL HEALTH NEEDS OF THE COMMUNITY BY OFFERING AND SUBSIDIZING MENTAL HEALTH SERVICES. WE ALSO SUBSIDIZE THE BULLHOOK COMMUNITY HEALTH CENTER WHICH WAS FORMED TO MEET THE NEEDS OF THE UNINSURED AND UNDERINSURED.BEGINNING IN FY 2011 NORTHERN MONTANA HOSPITAL BECAME A MEMBER OF THE HILL COUNTY HEALTH CONSORTIUM. THE CONSORTIUM IS COMPOSED OF MANY IMPORTANT STAKEHOLDERS IN OUR COMMUNITY WHO HAVE JOINED TOGETHER. WORKING TOGETHER, THE CONSORTIUM MEMBERS CONTRIBUTED A GREAT DEAL OF TIME AND RESOURCE TO COMPLETE THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE CHANGE (COMMUNITY HEALTH ASSESSMENT AND GROUP EVALUATION) TOOL FROM THE CDC WEBSITE WAS CHOSEN TO HELP US THROUGH THE PROCESS OF OUR COMMUNITY HEALTH ASSESSMENT MAINLY BECAUSE IT WOULD WALK US THROUGH EACH STEP IN THE PROCESS. CHANGE CAN BE USED TO GAIN A PICTURE OF THE POLICY, SYSTEMS, AND ENVIRONMENTAL CHANGE STRATEGIES CURRENTLY IN PLACE THROUGHOUT THE COMMUNITY; DEVELOP A COMMUNITY ACTION PLAN FOR IMPROVING POLICIES, SYSTEMS, AND THE ENVIRONMENT TO SUPPORT HEALTHY LIFESTYLES; AND ASSIST WITH PRIORITIZING COMMUNITY NEEDS AND ALLOCATING AVAILABLE RESOURCES. THE CHANGE TOOL INVOLVES DIVIDING OUR COMMUNITY INTO 5 DIFFERENT SECTORS AND CHOOSING A FEW SITES WITHIN THOSE SECTORS TO COLLECT RESPONSES FROM. THE 5 SECTORS INCLUDE:(1) COMMUNITY-AT-LARGE(2) COMMUNITY-INSTITUTIONS-ORGANIZATIONS(3) WORKSITE(4) HEALTH CARE(5) SCHOOLSALONG WITH THE CHANGE TOOL, A WRITTEN SURVEY WAS CREATED USING AN EXAMPLE FROM WILKES HEALTHY CAROLINIANS COUNCIL (WILKESHEALTH.COM). THIS SURVEY SEEMED TO FIT CLOSELY WITH OUR NEEDS, WITH ONLY MINOR ADJUSTMENTS BEING MADE TO FIT HILL COUNTY. THIS WRITTEN SURVEY WAS AVAILABLE THROUGHOUT HILL COUNTY AT VARIOUS WAITING AREAS SO PEOPLE WOULD HAVE ADEQUATE TIME TO COMPLETE THEM.
    PART VI, LINE 3: NORTHERN MONTANA HOSPITAL INFORMS AND EDUCATES PATIENTS ABOUT THEIR ELIGIBILITY FOR ASSISTANCE THROUGH A SIGN POSTED AT OUR ADMISSIONS DESK, NOTED IN THE BROCHURE WE GIVE PATIENTS AT OUR CLINICS, AND SIGNS POSTED AT OUR CLINIC REGISTRATION DESKS. IN ADDITION, OUR COLLECTION STAFF OFFERS CHARITY CARE AS AN OPTION WHEN THEY ARE DISCUSSING THE PATIENT'S BALANCE AS WELL AS THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS. AS OF OCT 2010, NMH HAS CONTRACTED WITH A COMPANY TO ASSIST THE PATIENT WITH QUALIFICATION FOR PROGRAMS SUCH AS MEDICAID AND DISABILITY DETERMINATION.WE ALSO PUBLISH A COMMUNITY BENEFIT REPORT ANNUALLY WHICH STATES HOW MUCH CHARITY CARE WE HAVE GIVEN AWAY, AND WE POST OUR COMMUNITY BENEFIT REPORT ON OUR WEBSITE NOTING THAT WE PROVIDE CHARITY CARE.
    PART VI, LINE 4: NORTHERN MONTANA HOSPITAL IS A 49 BED HOSPITAL INCLUDING 5 SWING BEDS, A 5 BED INTENSIVE CARE UNIT, EMERGENCY ROOM, SAME DAY SURGERY, AND A 6 CHAIR DIALYSIS UNIT; NORTHERN MONTANA CARE CENTER, A 136 BED SKILLED AND INTERMEDIATE CARE FACILITY OF WHICH 20 BEDS ARE DESIGNATED FOR RESIDENT'S WITH ALZHEIMER'S DISEASE AND OTHER RELATED DEMENTIAS; NORTHERN MONTANA ASSISTED LIVING, A 10 BED FACILITY; NORTHERN MONTANA MEDICAL GROUP - EAST, A RURAL HEALTH CLINIC; NORTHERN MONTANA MEDICAL GROUP - WEST, A RURAL HEALTH CLINIC; NORTHERN MONTANA VISION CENTER, AN OPHTHALMOLOGY OFFICE; NORTHERN MONTANA HOME MEDICAL EQUIPMENT (OPERATIONS DISCONTINUED 12/31/2010), BEAR PAW HOSPICE, AND THE HI-LINE SLEEP CENTER. THE HOSPITAL'S SERVICE AREA CONSISTS OF HILL, BLAINE, LIBERTY, PHILIPS AND THE BIG SANDY CENSUS DISTRICT OF CHOTEAU COUNTIES. THE POPULATION OF THIS SERVICE AREA IS APPROXIMATELY 30,000. THE MEDIAN HOUSEHOLD INCOME IS ABOUT $37,000. APPROXIMATELY 45% OF THE POPULATION HAS A HOUSEHOLD INCOME BELOW 200% OF THE FEDERAL POVERTY GUIDELINES. APPROXIMATELY 23% OF THE POPULATION IS COVERED BY MEDICAID, 30% BY MEDICARE, 2.41% BY CHIP AND ABOUT 10.4% UNINSURED. ADDITIONALLY, ANOTHER 8% OF THE POPULATION IS COVERED BY INDIAN HEALTH SERVICES. THE ENTIRE SERVICE AREA IS CONSIDERED RURAL AND HAS BEEN DESIGNATED A HEALTH PROFESSIONAL SHORTAGE AREA FOR ALL PRIMARY MEDICAL CARE, MENTAL HEALTH AND DENTAL. IN ADDITION, THE ENTIRE SERVICE AREA IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA. NORTHERN MONTANA HOSPITAL IS THE ONLY LOCAL HOSPITAL IN ITS SERVICE AREA, HOWEVER THERE ARE 3 CRITICAL ACCESS HOSPITALS, 4 RURAL HEALTH CLINICS, 3 COMMUNITY HEALTH CLINICS AND 3 IHS-TRIBAL CLINICS WITHIN ITS SERVICE AREA. THE NEAREST HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND IS 35 MILES AWAY.
    PART VI, LINE 6: NORTHERN MONTANA HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY. THE ORGANIZATION APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE BY KEEPING ITS MEDICAL EQUIPMENT UP TO DATE, SENDING ITS EMPLOYED PHYSICIANS FOR FURTHER CONTINUING EDUCATION, SUPPORTING NURSING EDUCATION THROUGH A LOAN RE-PAYMENT ASSISTANCE PROGRAM AND SUPPORTING HEALTH CARE EDUCATION THROUGH AN EDUCATION ASSISTANCE PROGRAM. IN ADDITION, THE HOSPITAL SUBSIDIZES ITS EMERGENCY DEPARTMENT BY OFFERING 24/7 EMERGENT CARE COVERAGE TO ALL, REGARDLESS OF THEIR ABILITY TO PAY. NORTHERN MONTANA HOSPITAL ALSO PARTICIPATES IN ALL GOVERNMENT SPONSORED HEALTH PROGRAMS, SUCH AS CHIP, HEALTHY MONTANA KIDS AND THE MONTANA CERVICAL AND BREAST CANCER PROGRAM, WHERE IT ACCEPTS PAYMENTS FOR SERVICES AT GREATLY DISCOUNTED RATES. SEVERAL MEMBERS OF NORTHERN MONTANA HOSPITAL'S LEADERSHIP TEAM SERVE ON OTHER COMMUNITY BOARDS, SUCH AS: HAVRE CHAMBER OF COMMERCE, HILL COUNTY HEALTH CONSORTIUM, LOCAL EMERGENCY PLANNING, FETAL/INFANT/CHILD MORTALITY REVIEW BOARD, HAVRE/HILL COUNTY PLANNING BOARD, HILL AND BLAINE COUNTY ADULT PROTECTIVE SERVICES COMMITTEE, HILL COUNTY UNITED WAY, HRDC MEDICAL ADVISORY BOARD, MSU-N NURSING ADVISORY BOARD AND THE SAFE KIDS SAFE COMMUNITIES COMMITTEE.
    PART VI, LINE 7: N/A
REPORTS FILED WITH STATES PART VI, LINE 7 MT
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number
81-0231787
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance






















2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
 
3
Enter total number of other organizations ................................ . Bullet Image
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) EDUCATION ASSISTANCE 5 9,152      













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES EDUCATION ASSISTANCE TO QUALIFIED EMPLOYEES. THE ORGANIZATION MONITORS THE USE OF THE ASSISTANCE BY DISBURSING THE FUNDS DIRECTLY TO THE INSTITUTION. THE ORGANIZATION ALSO PROVIDES SUPPORT TO A RELATED TAX-EXEMPT ORGANIZATION IN SUPPORT OF THEIR EXEMPT PURPOSE.
OTHER INFORMATION: PART IV: PER OUR EDUCATION ASSISTANCE POLICY, WE WILL ONLY ASSIST FOR DEGREES THAT WILL FULFILL OUR STAFFING NEEDS. WE WILL PAY UP TO $5,250 PER EMPLOYEE PER YEAR, HOWEVER NOT EVERY APPLICANT REQUESTS THE FULL AMOUNT. THEREFORE, WE ANTIPATE 3-6 RECIPIENTS PER YEAR.
Schedule I (Form 990) 2010


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
Yes
 
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) DAVID C HENRY (i)
(ii)		 275,250
0 		72,000
0 		0
0 		0
0 		0
0 		347,250
0 		0
0
(2) BRUCE RICHARDSON MD (i)
(ii)		 321,539
0 		0
0 		1,188
0 		0
0 		21,131
0 		343,858
0 		0
0
(3) STEPHEN BECHDOLT MD (i)
(ii)		 276,078
0 		0
0 		1,188
0 		0
0 		13,474
0 		290,740
0 		0
0
(4) MARGARET DOW MD (i)
(ii)		 205,941
0 		0
0 		168
0 		0
0 		24,756
0 		230,865
0 		0
0
(5) MICHAEL NOLAN MD (i)
(ii)		 254,970
0 		0
0 		1,188
0 		0
0 		5,310
0 		261,468
0 		0
0
(6) JOEL CLEARY MD (i)
(ii)		 345,098
0 		0
0 		710
0 		0
0 		4,424
0 		350,232
0 		0
0
(7) KAREN E LIEN MD (i)
(ii)		 319,446
0 		0
0 		210
0 		0
0 		23,685
0 		343,341
0 		0
0
(8) JOHN TRUE MD (i)
(ii)		 350,000
0 		0
0 		2,286
0 		0
0 		3,068
0 		355,354
0 		0
0
(9) SHAHRIAR ANOUSHFAR MD (i)
(ii)		 348,341
0 		0
0 		25,884
0 		0
0 		10,921
0 		385,146
0 		0
0
(10) SUZANNE SWIETNICKI MD (i)
(ii)		 243,447
0 		0
0 		414
0 		0
0 		23,565
0 		267,426
0 		0
0






Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
  PART I, LINE 5 PART I, LINE 5: TWO PHYSICIANS LISTED IN PART VII OF THE FORM 990 ARE COMPENSATED AS A PERCENTAGE OF THE PRIOR THREE MONTHS' AVERAGE GROSS REVENUE EARNED FOR THE HOSPITAL BY THE PHYSICIAN, WITH THE PERCENTAGE BEING BASED ON THEIR SPECIALTY.
SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 3: THE CEO/PRESIDENT OF NORTHERN MONTANA HOSPITAL IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, FUNDAMENTAL FINANCIAL GROUP, FOR HIS SERVICES PROVIDED TO NORTHERN MONTANA HOSPITAL, NORTHERN MONTANA HEALTH CARE FOUNDATION, INC., AND NORTHERN MONTANA HEALTH CARE, INC. HE SERVES 40 HOURS PER WEEK AT THE HOSPITAL, TWO (2) HOURS PER WEEK AT THE FOUNDATION, AND ONE (1) HOUR PER WEEK AT NORTHERN MONTANA HEALTH CARE, INC. THE BOARD WORKS WITH THE UNRELATED MANAGEMENT COMPANY TO DETERMINE THE CEO/PRESIDENT'S COMPENSATION USING THE METHODS CHECKED IN LINE 3.
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Identifier Return Reference Explanation
NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 VISITING NURSE SERVICES AVAILABLE JULY 1, 2010.
CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 HOME HEALTH CARE CLOSED JUNE 30, 2010 AND HOME MEDICAL EQUIPMENT CLOSED DECEMBER 31, 2010.
FORM 990, PART VI, SECTION A, LINE 3   THE PRESIDENT/CEO OF THE HOSPITAL IS EMPLOYED BY AN UNRELATED MANAGEMENT COMPANY.
FORM 990, PART VI, SECTION A, LINE 6   THE SOLE MEMBER OF THE ORGANIZATION IS NORTHERN MONTANA HEALTH CARE, INC.
FORM 990, PART VI, SECTION A, LINE 7B   THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE SUCH RIGHTS AND POWERS AS ARE PROVIDED FOR IN THE ARTICLES OF INCORPORATION, THE BYLAWS OF THE ORGANIZATION AND THE LAWS OF THE STATE OF MONTANA, INCLUDING BUT NOT LIMITED TO, THE EXCLUSIVE POWER: (A) TO REMOVE ANY TRUSTEE FROM ANY OFFICE AT ANY TIME, WITH OR WITHOUT CAUSE; (B) TO PROPOSE AND APPROVE (I) A PLAN OF DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION OR (II) A PLAN OF MERGER OR CONSOLIDATION OF THE ORGANIZATION WITH ANOTHER CORPORATION; (C) TO PROPOSE AND APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION AND OR THE BYLAWS;(D) TO ADOPT ANY ANNUAL OR LONG-TERM CAPITAL OR OPERATIONAL BUDGET OR ANY CHANGES THEREIN EXCEEDING $75,000;(E) TO AUTHORIZE THE ORGANIZATION TO ENTER INTO ANY CONTRACT OR ENGAGE IN ANY TRANSACTION WHICH IS NOT PROVIDED FOR IN AN ANNUAL OR LONG-TERM CAPITAL OR OPERATIONAL BUDGET APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION WHERE THE AMOUNT INVOLVED EXCEEDS $50,000;(F) TO ADOPT SUBSTANTIVE CHANGES TO EXISTING LONG-TERM OR MASTER INSTITUTIONAL PLANS OF THE ORGANIZATION; (G) TO AUTHORIZE THE ORGANIZATION TO ENGAGE IN, OR ENTER INTO, ANY TRANSACTION PROVIDING FOR THE SALE, MORTGAGE OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION; (H) TO ORGANIZE OR ACQUIRE, OR AUTHORIZE THE ORGANIZATION OR ACQUISITION OF, ANY SUBSIDIARY OR AFFILIATE OF THE ORGANIZATION; (I) TO AUTHORIZE THE ORGANIZATION TO ENTER INTO ANY SHARED SERVICE AGREEMENT; (J) TO APPROVE LONG-TERM BORROWING OF MONEY BY THE ORGANIZATION OR AUTHORIZE THE ORGANIZATION TO INCUR INDEBTEDNESS INVOLVING A MORTGAGE OR LIEN ON ASSETS; OR (K) TO APPROVE THE TRUSTEES OR THE PRESIDENT OF THE ORGANIZATION FROM A SLATE PREPARED BY THE NOMINATING COMMITTEE OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 8B   NO COMMITTEE HAS THE AUTHORITY TO ACT ON BEHALF OF THE BOARD.
FORM 990, PART VI, SECTION B, LINE 11   A DRAFT COPY OF THE FORM 990 WILL BE REVIEWED BY THE VP OF FINANCE, THEN SUBMITTED VIA E-MAIL TO THE BOARD OF DIRECTORS TO VIEW BEFORE FILING.
  FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL TRUSTEES, DIRECTORS, OFFICERS, AND KEY EMPLOYEES. THE BOARD IDENTIFIES POTENTIAL CONFLICTS FROM ANNUAL DISCLOSURES. DISCLOSURES ARE REVIEWED BY ADMINISTRATION AFTER ALL ARE GATHERED. A SECOND CONFLICT DISCLOSURE LETTER IS SENT OUT ANNUALLY TO ALL CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TO ENSURE ALL POTENTIAL CONFLICTS ARE IDENTIFIED. THE RESULTS OF THIS DISCLOSURE FORM ARE REVIEWED BY THE VP OF FINANCE. THE BOARD DISCUSSES THE POTENTIAL CONFLICTS AND DETERMINES IF VOTING ON RELATED ITEMS WOULD BE A CONFLICT OF INTEREST. IF A CONFLICT IS DETERMINED TO EXIST, THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE CONFLICTED ITEM.
  FORM 990, PART VI, SECTION B, LINE 15A THE CEO/PRESIDENT IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY. THE EXECUTIVE COMMITTEE OF THE BOARD MEETS AND REVIEWS NORTHERN MONTANA HOSPITAL(NMH)/NORTHERN MONTANA HEALTH CARE, INC.(NMHC) FINANCIAL RESULTS, THE CEO'S CURRENT YEAR PRIORITIES, DISCUSS EVALUATION TOOLS TO BE USED FOR CEO EVALUATION, HOW COMPARATIVE SALARIES WILL BE OBTAINED AND DISCUSS THE HISTORY OF COMPENSATION TO THE CEO. AT A SECOND EXECUTIVE COMMITTEE MEETING THEY REVIEW NON-FINANCIAL ACTIVITY OF NMH/NMHC AND THE RESULTS OF THE CEO EVALUATIONS COMPLETED BY THE BOARD MEMBERS. THEN THEY REVIEW AND DISCUSS A COMPENSATION COMPARATIVE SUMMARY OF MONTANA CEO'S COMPENSATION AND A GUIDESTAR CEO COMPENSATION CHECKPOINT THAT IS PREPARED SPECIFICALLY FOR NMH. THEY AGREE UPON A LIST OF THE COMING YEAR'S PRIORITIES FOR THE CEO AND PROPOSED COMPENSATION, WITH THE COMPENSATION SET BY BOARD VOTE. THIS ANNUAL PROCESS WAS LAST PERFORMED DURING THE TAX YEAR ENDED JUNE 30, 2011.
  FORM 990, PART VI, SECTION C, LINE 19 FORM 990, PART VI, SECTION C, LINE 19: THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER THE IRS INSTRUCTIONS.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 503,536. MINIMUM PENSION LIABILITY ADJUSTMENT: 2,439,058. EQUITY TRANSFER TO RELATED ORGANIZATION: -500,000. ROUNDING 2. TOTAL TO FORM 990, PART XI, LINE 5: 2,442,596.
  FORM 990, PART XII, LINE 2C: THE CONTROLLING ORGANIZATION, NORTHERN MONTANA HEALTH CARE, INC.'S BOARD HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT AUDITOR.
ORGANIZATIONS: FORM 990, PART VII, SECTION A, PERCENTAGE OF TIME SPENT BETWEEN RELATED NO INDIVIDUALS ARE COMPENSATED FOR THEIR BOARD SERVICE TO EITHER ORGANIZATION, ONLY FOR THEIR SERVICE AS EMPLOYEES OF THE HOSPITAL. THE FOLLOWING INDIVIDUALS SPEND 2% OF THEIR TIME ON NMHC BUSINESS AND 98% OF THEIR TIME ON NMH BUSINESS: -VICE PRESIDENT OF NMHC ALSO SERVES AS THE VP OF NMH. -THE VICE CHAIR OF NMHC ALSO SERVES AS THE VICE CHAIR AND AN EMPLOYED PHYSICIAN OF NMH. -THREE TRUSTEES OF NMHC ALSO SERVE AS TRUSTEES AND EMPLOYED PHYSICIANS (INCLUDING THE MEDICAL DIRECTOR AND CHIEF OF STAFF) OF NMH. THE FOLLOWING INDIVIDUALS SPEND 2% OF THEIR TIME ON NMHC BUSINESS AND 2% OF THEIR TIME ON NMHCF BUSINESS AND 96% OF THEIR TIME ON NMH BUSINESS: -CEO/PRESIDENT OF NMHC ALSO SERVES AS THE CEO/PRESIDENT OF NMH AND NMHCF. -VP OF FINANCE OF NMHC ALSO SERVES AS THE VP OF FINANCE OF NMH AND NMHCF. THE REMAINING MEMBERS OF THE BOARD OF TRUSTEES SPEND 50% OF THEIR TIME ON NMHC BUSINESS AND 50% OF THEIR TIME ON NMH BUSINESS. NONE OF THEM ARE EMPLOYED BY EITHER ORGANIZATION.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTHERN MONTANA HOSPITAL
 
Employer identification number

81-0231787
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) NORTH CARE CORPORATION

30 13TH STREET

HAVRE,MT59501
81-0447638 		SUPPORTING ORGANIZATION MT 501(C)(3) LINE 3 NORTHERN MONTANA HEALTH CARE INC
 
 
No
(2) NORTHERN MONTANA HEALTH CARE INC

PO BOX 1231

HAVRE,MT59501
81-0428854 		SUPPORTING ORGANIZATION MT 501(C)(3) LINE 11B, II N/A
 
No
(3) NORTHERN MONTANA HEALTH CARE FOUNDATION INC

PO BOX 1231

HAVRE,MT59501
36-3464641 		FUNDRAISING MT 501(C)(3) LINE 7 NORTHERN MONTANA HEALTH CARE INC
 
 
No








For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership












Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


Software ID:  
Software Version: