TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Gordon Harman Board DIRECTOR thru 12/11	1.0	X		0	0	0
(2) Marjorie Kuchynka Board SECRETARY/TREASURER	1.0	X	X	0	0	0
(3) Larry Coonts Board Director thru 8/11	1.0	X		0	0	0
(4) Maurice Masar MD Board Director	1.0	X		0	0	0
(5) Gary Rehder Board VICE CHAIR	1.0	X	X	0	0	0
(6) Dan Davis Board CHAIR	1.0	X	X	0	0	0
(7) Sister Mary Rochefort Board Director	1.0	X		0	0	0
(8) Sister Barbara Jean Glodowski Board Director	1.0	X		0	0	0
(9) Bryan Higgins Board Director	1.0	X		0	0	0
(10) Lee Pippenger Board Director	1.0	X		0	0	0
(11) Michael Hedrix Board Director	60.0	X		0	353,852	88,322
(12) Andrew Gilbert MD Board Director THRU 9/11	40.0	X		0	221,321	21,056
(13) Kelly McGrath MD Board Director	40.0	X		213,704		33,279
(14) HENRY CLAY BOARD DIRECTOR thru 9/11	1.0	X		0	0	0
(15) Alvin SECREST III MD Board Director	40.0	X		0	240,307	35,347
(16) LONNIE SIMPSON BOARD DIRECTOR	1.0	X		0	0	0
(17) Colleen Meza President	50.0		X	0	298,625	67,718

(A) Name and business address	(B) Description of services	(C) Compensation
Palouse Imaging Consultants PO Box 9583 MOSCOW,ID83843	Radiology Services	301,020
GRITMAN MEDICAL CENTER 700 S MAIN STREET MOSCOW,ID83843	RADIOLOGY SERVICES	251,037
WENDI RICHARDSON PO BOX 1916 OROFINO,ID83544	CRNA	186,229
DMS Imaging Inc 26273 NETWORK PLACE CHICAGO,IL60673	Mobile Radiology	287,197

2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 4

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 United States. See Part IV, line 21	1,575	1,575
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	501,696	203,401	298,295
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	9,098,473	7,944,189	1,106,684	47,600
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	324,018	283,279	39,037	1,702
9	Other employee benefits .......	1,082,935	934,031	143,525	5,379
10	Payroll taxes ...........	644,558	556,839	84,457	3,262
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	1,922		1,922
c	Accounting ...........	52,947		52,947
d	Lobbying ...........	1,512		1,512
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	4,520		4,520
g	Other ..........	1,851,085	1,758,977	91,308	800
12	Advertising and promotion ....	32,926		32,926
13	Office expenses .......	1,613,223	1,431,168	178,314	3,741
14	Information technology ......	166,402	119,597	45,492	1,313
15	Royalties ..	0
16	Occupancy ...........	274,536	206,521	66,275	1,740
17	Travel ............	153,696	118,825	33,893	978
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	71,247	58,790	12,272	185
20	Interest ...........	14,313	7,605	6,708
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	550,191	395,435	150,414	4,342
23	Insurance ..............	225,433	216,467	8,966
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	BAD DEBT EXPENSE	1,210,135	1,210,135
b	MEDICAL SUPPLIES	555,461	555,461
c	AFFILIATE SUPPORT FEE	431,436		431,436
d	DUES & SUBSCRIPTIONS	138,451	28,287	109,994	170
e
f	All other expenses	137,489	137,489
25	Total functional expenses. Add lines 1 through 24f	19,140,180	16,168,071	2,900,897	71,212
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	425	1	725
2	Savings and temporary cash investments .......	1,058,997	2	2,075,777
3	Pledges and grants receivable, net .........	73,869	3	84,635
4	Accounts receivable, net .........	3,970,612	4	3,629,626
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........	0	5	0
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 ..........	0	6	0
7	Notes and loans receivable, net .............	34,000	7	15,000
8	Inventories for sale or use ..............	488,953	8	420,413
9	Prepaid expenses and deferred charges ............	63,639	9	69,581
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	6,716,947
b	Less: accumulated depreciation. .....	10b	3,652,562	2,430,857	10c	3,064,385
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 ......	1,148,024	12	444,003
13	Investments—program-related. See Part IV, line 11 ..	0	13	0
14	Intangible assets .........	0	14	0
15	Other assets. See Part IV, line 11 ...........	0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)...	9,269,376	16	9,804,145
	17	Accounts payable and accrued expenses .	1,733,992	17	1,784,673
18	Grants payable ..........	0	18	0
19	Deferred revenue ..........	0	19	0
20	Tax-exempt bond liabilities ..........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	111,801	23	126,510
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	1,184,877	25	1,161,403
26	Total liabilities. Add lines 17 through 25.....	3,030,670	26	3,072,586
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	6,238,706	27	6,731,559
28	Temporarily restricted net assets .....	0	28	0
29	Permanently restricted net assets .....	0	29	0
	Organizations that do not follow SFAS 117, check here 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 .....	6,238,706	33	6,731,559
34	Total liabilities and net assets/fund balances .....	9,269,376	34	9,804,145

- TIN:

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.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

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.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2011. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2010. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2011

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) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2011

Name of organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... 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 on line H of its
Form 990-EZ or on Part I, 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) (2011)

Page 2

Name of organization Clearwater Valley Hospital and Clinics Inc
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part I	Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3

Name of organization Clearwater Valley Hospital and Clinics Inc
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part II	Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2011)

Page 4

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization
Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total 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

$
Use duplicate copies of Part III if additional space is needed

(a) No.
from
Part I

(b)
Purpose 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

(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

(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

(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) (2011)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

1,512

Total. Add lines 1c through 1i ...............................

1,512

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
Schedule C, Part II-B		Lobbying Activity Explanation: Clearwater Valley Hospital and Clinics, Inc. pays dues to certain organizations related to the industry which have lobbying expenses. The amount listed is the percentage of the dues paid that were used for lobbying.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

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 .......

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? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can 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? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax 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, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

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)? ....................................

Yes No

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.

If the organization elected, as permitted under SFAS 116 (ASC 958), 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.

If the organization elected, as permitted under SFAS 116 (ASC 958), 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

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 (ASC 958), relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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) 2011

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

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?........

Yes No

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.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

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	Net investment earnings, gains, and losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	116,169		116,169
b	Buildings ................	1,402,516	672,916	729,600
c	Leasehold improvements ............	6,211	3,106	3,105
d	Equipment ................	4,969,763	2,950,138	2,019,625
e	Other .................	222,288	26,402	195,886
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				3,064,385

Schedule D (Form 990) 2011

Page 3

Part VII

InvestmentsOther 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) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram 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) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
BUILDING LEASE LIABILITY		819,278
PAYABLES TO RELATED TAX-EXEMPT ORGS		342,125







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,161,403
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) 2011

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 through 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 must 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 must 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
Schedule D, Part X		ASC 740 footnote: Essentia Health has adopted Accounting Standards Codification 740, Income Taxes (formerly known as FASB Interpretation No. 48 (FIN 48), Accounting for Uncertainty in Income Tax - an interpretation of FASB Statement No. 109, Accounting for Income Taxes). The adoption of this interpretation had no material impact on the consolidated financial statements and therefore, Essentia Health's consolidated financial statements for fiscal year ended June 30, 2012 no longer includes an ASC 740 footnote.

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

2011

Open to Public Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the

following was the family income limit for eligibility for discounted care: ............

Yes

200% 250% 300% 350% 400% Other

If the organization did 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 used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

If "Yes," did the organization make it available to the public? ...............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

	(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 Financial Assistance at cost (from Worksheet 1) ..		98	232,073	0	232,073	1.290 %
b Medicaid (from Worksheet 3, column a) .....		3,754	2,441,894	2,008,404	433,490	2.420 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .		0	0	0	0	0 %
dTotal Financial Assistance and Means-Tested Government Programs .....		3,852	2,673,967	2,008,404	665,563	3.710 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	6	4,378	110,826	0	110,826	0.620 %
f Health professions education (from Worksheet 5) ..	5	34	64,246	0	64,246	0.360 %
g Subsidized health services (from Worksheet 6) ..		0	0	0	0	0 %
h Research (from Worksheet 7)		0	0	0	0	0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	6	1,167	22,570	0	22,570	0.130 %
jTotal Other Benefits ...	17	5,579	197,642	0	197,642	1.110 %
kTotal. Add lines 7d and 7j. ..	17	9,431	2,871,609	2,008,404	863,205	4.820 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(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		0	0	0	0	0 %
2	Economic development		0	0	0	0	0 %
3	Community support		0	0	0	0	0 %
4	Environmental improvements		0	0	0	0	0 %
5	Leadership development and training for community members		0	0	0	0	0 %
6	Coalition building		0	0	0	0	0 %
7	Community health improvement advocacy		0	0	0	0	0 %
8	Workforce development		0	0	0	0	0 %
9	Other		0	0	0	0	0 %
10	Total		0	0	0	0	0 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense........

1,210,135

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

16,209

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

Enter total revenue received from Medicare (including DSH and IME).....

8,440,106

Enter Medicare allowable costs of care relating to payments on line 5.....

8,356,541

Subtract line 6 from line 5. This is the surplus or (shortfall)........

83,565

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

(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) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	Clearwater Valley Hospital and Clinics 301 Cedar Ave Orofino,ID83544	X	X	X	X

Schedule H (Form 990) 2011

Page

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)

Clearwater Valley Hospital and Clinics

Name of Hospital Facility:

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 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 100% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 200.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13		No
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?4
Name and address		Type of Facility (describe)
1	KOOSKIA MEDICAL CLINIC 201 THENON STREET KOOSKIA,ID83539	PROVIDER BASED CLINIC
2	PIONEER MEDICAL CLINIC PO BOX 340 CARLE STREET PIERCE,ID83546	RURAL HeaLTH CLINIC & VISITING NURSE SERVICE
3	OROFINO MEDICAL CENTER 301 CEDAR AVE OROFINO,ID83544	PROVIDER BASED CLINIC
4	OROFINO PHYSICAL THERAPY CLINIC 153 JOHNSON AVE OROFINO,ID83544	PHYSICAL THERAPY CLINIC
5
6
7
8
9
10

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions 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, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any 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
Schedule H, Part VI, Line 1		Provide the description required for Part I, lines 3c, 6a, 7g, 7, column (f), 7; Part II; Part III, lines 4, 8, 9b; Part V, lines 1j, 3, 4, 5c, 6i, 7, 11h, 13g, 15e, 16e, 18c, 18d, 19d, 20, 21: Part I, line 3c If asset levels are deemed to be significant, no discounted or free care will be offered, even if they meet the income thresholds. Part I, line 6a Clearwater Valley Hospital & Clinics, Inc's community benefit information is consolidated into the Essentia Health community benefit information which is included in the Essentia Health annual report. The annual report is made available to the public via the website at www.essentiahealth.org. Essentia Health, headquartered in Duluth, Minn., is an integrated health system serving patients in Minnesota, Wisconsin, North Dakota and Idaho and is Clearwater Valley Hospital & Clinics, Inc's parent corporation. Part 1, line 7g not applicable. Part I, line 7, column (f) Bad debt expense that was subtracted from total expense to obtain the % of community benefit to total expense amounted to $1,210,135. Part I, line 7 The cost to charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges was used to calculate the costs for the following community benefits: Charity Care and Unreimbursed Medicaid. Actual costs were used for the remainder of the community benefits reported. Part II - Describe how the organization's community building activities, as reported in Part II, promote the health of the communities the organization serves: Not applicable. Part III, line 4 Discounts, charity care, and bad debt expense are accounted for as reductions to revenue. Bad debt expense on patient accounts would be identified as any balance on the account, less any previous payments and discounts, that has aged and is absent of any payments. If, during the collection process, it becomes known that the patient qualifies for charity care, the amounts included within bad debt expense would be reclassified to charity care. Part III, Line 4 A record review was completed of all denied charity care applications for FY2011. It was found that 20% of denials were due to incomplete documentation. These denials totaled $16,000. Part III, Line 4 Clearwater Valley Hospital & Clinics, Inc. is a part of a larger organization, Essentia Health. Essentia Health and its member organizations incorporate the cost of bad debt as a community benefit. As a tax exempt hospital, we must provide the necessary services regardless of the patient's ability to pay for that care. In doing so, Essentia Health makes quality patient care available to all in our community, regardless of their economic means. Part III, line 4 (Excerpt from the parent company's audit) Accounts receivable are stated at net realizable value. The allowance for uncollectible accounts is based upon management's ongoing assessment of historical and expected net collections for each major payor source considering historical business and economic conditions, trends in healthcare coverage, and other collection indicators. For receivables associated with private-pay patients, Essentia records a significant provision for uncollectible accounts in the period of service on the basis of its historical experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. Part III, line 8 The costing methodology used in determining the Medicare Allowable Cost reported in the organization's Medicare Cost Report is to take total Medicare costs from the general ledger system and then follow the instructions provided by Centers for Medicare Services (CMS) to back off all costs not allowable. From the Medicare allowable costs, any costs attributable to subsidized health services and costs attributable to GME were subtracted, if applicable. Part III, line 8 Clearwater Valley Hospital & Clinics, Inc. is a part of a larger organization, Essentia Health. Essentia Health and its member organizations incorporate the full value of the Medicare shortfall as a community benefit. The rationale for the organization's opinion is providing care for the elderly and serving Medicare patients is an essential part of the community benefit standard. Medicare, like Medicaid, does not pay the full cost of care and it is likely to get worse. Many Medicare beneficiaries are poor and are eligible for Medicaid in addition to Medicare. Medicare underpayment must be shouldered by the hospital in order to continue treating the community's elderly and poor. These underpayments represent a real cost of serving the community. Part III, line 8 Each Essentia Health hospital is required to file a Medicare cost report 5 months after the close of their fiscal year. The cost report provides Medicare with information that is used to determine utilization and spending trends but also is used to set future payment rates for most Medicare services. If the interim payments paid to a hospital are higher or lower than the filed cost report allowable reimbursement there will be a settlement for that fiscal year. This can be due to changes in utilization or cost of providing services for Critical Access Hospitals (CAH) or differences between interim and final payment factors for Disproportionate Share, Bad Debts, or Indirect Medical Education for non-CAH hospitals. An estimate for these settlements is recorded at the close of the fiscal year. If the estimate varies from the final settlement received 6-7 months after the fiscal year ends then these amounts are recorded as prior year Medicare revenue. Part III, line 9b At any stage of the patient experience, including collections, a determination may be made that the patient qualifies for Financial Assistance. All collection efforts must be suspended while a patient's Financial Assistance application is being considered and until the patient is notified regarding the determination of eligibility. Once eligibility (or lack of eligibility) is determined, amounts still owed by patients will be collected in the same manner as all other patient bills.
Part V, Line 11h		not applicable. PART V, LINE 13 Clearwater Valley Hospital & Clinics did not have language in their financial assistance policy stating how the policy was to be publicized as of year-end. Since year end, the policy has been revised to add language stating how the policy was to be publicized. Part VI, line 3 describes how Clearwater Valley Hospital & Clinics informed patients of the financial assistance policy. PART V, LINE 13G not applicable. PART V, LINE 15E not applicable. PART V, LINE 16E not applicable. PART V, LINE 17E not applicable. PART V, LINE 18C not applicable. PART V, LINE 18D not applicable. PART V, LINE 19D For patients known to qualify for the financial assistance program, discounts will be applied to billed amounts if the patient qualifies for discounted care and the billed amount will be fully discounted if the patient qualifies for free care. PART V, LINE 20 not applicable PART V, LINE 21 not applicable
Part VI, line 2		Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B. Clearwater Valley Hospital and Clinics, Inc. is overseen by a volunteer board of directors consisting of representatives of its service area. These directors bring community health needs to the table. In addition, service usage patterns are monitored by administrators, doctors are consulted for needed care improvements in monthly medical staff meetings, and an organization-wide quality council monitors quality improvement data regularly. We also have meetings every other month with community partners to assess specific population health indicators. Clearwater Valley Hospital and Clinics, Inc. is interpolating results obtained from a formal assessment performed in adjoining Idaho County.
Part VI, line 3		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: Notification of Financial Information including Charity Care is made widely available to the public in the admitting, billing and patient/family reception areas. Reference to the program is also contained in the hospital admissions packet. The Financial Counselor visits uninsured or underinsured patients or their family during their stay, whenever possible, to discuss financial arrangements. Charity Care applications, Medicaid applications, and County forms are distributed at that time. Follow up calls are made after discharge to finalize arrangements. This information is provided to anyone requesting it, whether they request it in person, by mail, or by phone. Signs indicating the availability of charity care are posted in the ER area, the inpatient family waiting room, business office and admitting area. The signs provide a phone number and contact information. All staff with public and patient contact, including but not restricted to billing and emergency staff will refer patients to the Financial Counselor for detailed explanations of the Charity Care program and to acquire forms. The Financial Counselor can then do the appropriate follow up. Based on the information gathered by the Financial Arrangement worksheet, the Financial Counselor will determine whether the account should be directed to a bank loan, Medicaid, County Social Services, or Charity Care. The patient will then complete the Determination Form and forward to the Collections Office Manager for approval.
Part VI, line 4		Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves: Clearwater Valley Hospital & Clinics, Inc. is located in Orofino, ID. Clearwater Valley Hospital & Clinics, Inc. is a part of the larger Essentia Health system, which is defined in Part VI, line 6. Clearwater Valley Hospital & Clinics, Inc. operates 1 hospital and 4 clinics that serve the communities of Idaho, Lewis and Clearwater counties covering 2,400 square miles. The overall community is classified as rural. Clearwater Valley Hospital & Clinics, Inc. cover a service region of approximately 10,000 people. The service region age distribution is 21.3% under the age of 18; 57.8% between the ages of 18 and 65; and 20.9% over the age of 65. The racial makeup of the service region is 91.3% Caucasian; 0.1% Black or African American; 4.7% American Indian or Alaskan Native; 0.5% Asian; 2.1% two or more races; and 1.3% other. The gender split ratio is 50.4% women and 49.6% men. The average income for the service area is approximately $43,000. Approximately 12.8% of the population falls below the federal poverty guidelines. Clearwater Valley Hospital & Clinics, Inc., along with Essentia Health is committed to serve patients regardless of their ability to pay. 4.5% net revenue dollars were from self pay patients. In addition, approximately 13.6% of their net revenue dollars were Medicaid recipients. A large portion of the population lacks medical insurance. As mentioned above, Clearwater Valley Hospital & Clinics, Inc. is part of a larger system, Essentia Health. Essentia Health staffs hospitals and clinics in federally-recognized underserved areas and supports the health of its communities through an active outreach program that brings specialists like oncologists, cardiologists, neurologists and others into its smaller communities. This eliminates barriers to care for many patients, particularly those who are elderly, living on low incomes, or are faced with other challenges that make it difficult to travel long distances for care. There are no other hospitals outside of the Essentia Health umbrella that service the community.
Part VI, line 5		Provide any other information important to describing how the organization's hospitals or other health care facilities further its exempt purpose by promoting the health of the community: Clearwater Valley Hospital and Clinics, Inc's board of directors is composed of volunteer representatives from the communities it serves. In addition, the hospital serves as a clinical practice site for many students in x-ray technology, nursing, physician assistant, nurse practitioner, and medical residency programs. This is especially important because Idaho has one of the lowest physician per capita rates in the nation. Recently Clearwater Valley Hospital & Clinics, Inc. has expanded its use of telehealth services to improve patient care. These types of services are extremely important for expanding access to health care in rural America. It takes close to 12 hours to drive from the northern part of our state to the southern border. Add to that river canyons, mountains and treacherous roads and you'll have a better understanding of the challenge of commuting to receive health care specialty services. The closest large urban centers are either three or five hours away. Having specialists 'see' our patients and consult with our physicians using teleconferencing and our Remote Presence (RP-7) robots allows us to access cardiologists, hospitalists, adult and child psychiatrists, surgical specialists, ED specialists and soon, a dermatologist. In our rural area we don't have the patient base necessary to establish full time specialty care. However, we have the same types of illnesses and injuries that people have in larger cities. Using technology to bring those specialists to our area so people can receive their healthcare locally is vital to providing a fuller range of medical care to our patients. Clearwater Valley Hospital & Clinics reviews the facilities and equipment and develops an attrition process to replace aging plant operations & equipment. Clearwater also looks for opportunities to bring new services to the communities via investing in new skills and technology where appropriate.
Part VI, Line 6		Clearwater Valley Hospital & Clinics, Inc. is part of Essentia Health, an integrated health system of 16 hospitals, 65 clinics and several long-term care facilities in four states: Minnesota, Wisconsin, North Dakota and Idaho. The health system serves a predominantly rural population whose median incomes generally fall below averages of the states where they live. The presence of our clinics and hospitals ensures that people with few economic resources don't have to drive an hour or more to receive basic (and in some cases live-saving) medical care. In addition to staffing hospitals and clinics in federally-recognized underserved areas, we support the health of our communities through an active outreach program that brings specialists like oncologists, cardiologists, neurologists and others into our smaller communities. This eliminates barriers to care for many patients, particularly those who are elderly, living on low incomes, or are faced with other challenges that make it difficult to travel long distances for care. Our size and integrated structure allow us to offer patients services often found only in larger urban settings. Services ranging from chemotherapy to congestive heart failure management and hospice are available to patients in many of the rural communities we serve. Essentia Health also supports the health of our rural communities through active research and clinical trials, through the Essentia Institute of Rural Health. The Institute conducts clinical, translational and health services research with a primary focus on the needs of rural Americans. Essentia Health is also serving patients through the use of the Epic electronic health record (EHR). The vast majority of Essentia's hospitals and clinics were using a fully-integrated EHR for patient care. Technology like the electronic health record and telehealth allows health clinicians to share test results and consult with colleagues in real time across great distances. Medical information is no longer lost in the shuffle of paper records - an important consideration in a region where patients must often be transferred to a larger Essentia facility for complex surgeries or medical care. Essentia is also actively working with government agencies and insurers to develop innovative, cost-effective approaches to care that will improve health outcomes while reducing overall costs to patients and insurers. This innovation can be found in our use of remote home monitors for patients with congestive heart failure to a focus on using a team-based approach to helping patients manage chronic diseases. Essentia Health is committed to helping patients and their families lead active and fulfilling lives in the small and large communities where they live. We hope to become a model of health care delivery, particularly in rural areas, in the years to come.
Part VI, Line 7		Clearwater Valley Hospital & Clinics files a community benefit report in Idaho.

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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

2011

Open to Public Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Part I

Questions Regarding Compensation

Yes

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.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....

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? ....

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. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

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:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

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.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

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 ............

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 Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(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 as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) Colleen Meza	(i) (ii)	0 204,670	0 53,834	0 40,121	0 60,607	0 7,111	0 366,343	0 39,792
(2) Lenne Bonner	(i) (ii)	117,345 0	18,520 0	0 0	8,660 0	23,376 0	167,901 0	0 0
(3) Clayton Bunt MD	(i) (ii)	181,525 0	22,036 0	0 0	12,284 0	18,781 0	234,626 0	0 0
(4) Michael Meza MD	(i) (ii)	180,769 0	36,222 0	0 0	16,078 0	18,243 0	251,312 0	0 0
(5) Enrique Montana MD	(i) (ii)	256,814 0	100 0	0 0	14,761 0	12,740 0	284,415 0	0 0
(6) Michael Hedrix	(i) (ii)	0 257,782	0 60,355	0 35,715	0 44,545	0 43,777	0 442,174	0 32,949
(7) Andrew Gilbert MD	(i) (ii)	0 129,683	0 91,638	0 0	0 9,973	0 11,083	0 242,377	0 0
(8) Kelly McGrath MD	(i) (ii)	156,586	57,118	0	12,663	20,616	246,983	0
(9) Larry Barker	(i) (ii)	107,205 0	30 0	0 0	6,307 0	19,332 0	132,874 0	0 0
(10) VANESSA BROWN MD	(i) (ii)	182,343 0	6,515 0	0 0	11,374 0	6,454 0	206,686 0	0 0
(11) Alvin SECREST III MD	(i) (ii)	0 207,411	0 32,896	0 0	0 14,073	0 21,274	0 275,654	0 0
(12) PHILLIP PETERSEN MD	(i) (ii)	174,718 0	4,237 0	0 0	10,316 0	22,076 0	211,347 0	0 0

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Form 990, Part I, Line 3		Methods used to establish CEO's compensation: Clearwater Valley Hospital and Clinics, Inc. relied on Critical Access Group's, supporting organization of Clearwater Valley Hospital and Clinics, Inc., methods for establishing Clearwater Valley Hospital and Clinics, Inc.'s President's compensation: a compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board or compensation committee.
Form 990, Part I, Line 4a		Larry Barker listed as a Former in Form 990, Par VII, Section A, Line 1a is still employed with Clearwater Valley Hospital and Clinics, Inc. and did not receive a severance payment during tax year 2011.
Form 990, Part I, Line 4b		Supplemental nonqualified retirement plan: Amounts related to participating in a supplemental nonqualified retirement plan are reported in Schedule J, Part II, Column C, and amounts related to receiving payment from a supplemental nonqualified retirement plan are reported in Schedule J, Part II, Column B (iii). The following individuals listed in Form 990, Part VII, Section A, Line 1a received payment from a supplemental nonqualified retirement plan during the year: Colleen Meza (Critical Access Group) $39,792 Michael Hedrix (Critical Access Group)) $32,949 Critical Access Group's nonqualified retirement plan is offered to Critical Access Group executives. There is a minimum two year vesting date, benefits are subject to income taxes upon vesting, and benefits are payable from Critical Access Group's general assets.

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE M
(Form 990)

Department of the Treasury

Internal Revenue Service

NonCash Contributions

Complete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image

Attach to Form 990.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Part I

Types of Property

	(a) Check if applicable	(b) Number of Contributions or items contributed	(c) Noncash contribution amounts reported on Form 990, Part VIII, line 1g	(d) Method of determining noncash contribution amounts
1 Art—Works of art ....
2 Art—Historical treasures .
3 Art—Fractional interests ..
4 Books and publications ..
5 Clothing and household goods .......
6 Cars and other vehicles ..
7 Boats and planes ....
8 Intellectual property ...
9 Securities—Publicly traded .
10 Securities—Closely held stock .
11 Securities—Partnership, LLC, or trust interests ....
12 Securities—Miscellaneous ..
13 Qualified conservation contribution—Historic structures .....
14 Qualified conservation contribution—Other ...
15 Real estate—Residential .
16 Real estate—Commercial ..
17 Real estate—Other ...
18 Collectibles .....
19 Food inventory ...
20 Drugs and medical supplies .
21 Taxidermy ......
22 Historical artifacts ....
23 Scientific specimens ..
24 Archeological artifacts ...
25 Other ( LAND )	X	1	60,000	COST
26 Other ( )
27 Other ( )
28 Other ( )

Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...

Yes

30a

During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it

must hold for at least three years from the date of the initial contribution, and which is not required to be used

for exempt purposes for the entire holding period? ..................

30a

If "Yes," describe the arrangement in Part II.

Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?

32a

Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash

contributions? ............................

32a

If "Yes," describe in Part II.

If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,

describe in Part II.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 51227J

Schedule M (Form 990) 2011

Page 2

Part II

Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Form 990, Column B		Number of contributions: Clearwater Valley Hospital and Clinics, Inc. is reporting the number of contributions. Form 990, Column D Method: Cost or selling price of donated property.

Schedule M (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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

2011

Open to Public
Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

Identifier	Return Reference	Explanation
Form 990, Part III, Line 4		Program service accomplishments: Clearwater Valley Hospital and Clinics, Inc. is created & organized exclusively for charitable, religious, educational & scientific purposes. Clearwater Valley Hospital and Clinics, Inc. is created & organized to own, maintain, operate & conduct, directly or indirectly, & to assist & coordinate activities of facilities for health care, education, care for the aged & social services. In keeping with its mission, Clearwater Valley is committed to serve all members of its communities by providing free care and/or subsidized care, care for the persons covered by governmental programs at below cost, & providing health activities & programs to support the community. During fiscal year 2012, Clearwater Valley had 791 admissions involving 2,860 hospital patient days and 38,087 outpatient visits in the hospital, emergency room, & clinics. Charity care is provided through many reduced price services & free programs offered throughout the year based upon activities & services which Clearwater Valley believes will serve a bona fide need. These include health fairs, immunizations clinics, health education classes, rural education training, & wellness programs. Clearwater Valley provided approximately $232,000 in charity care as well as an additional $433,000 of costs incurred in excess of Medicaid payments received during the fiscal year ended June 30, 2012. Further community benefits provided during the fiscal year include education and workforce development of over $64,000, community services of over $110,000, and cash & in-kind donations of over $22,000.
Form 990, Part VI, Line 2		Family relationship: Lenne Bonner, current officer, and Bryan Higgins, current director, have a family relationship.
Form 990, Part VI, Line 6		Members of organization: Critical Access Group may elect one or more members of the governing body as described in Schedule O Part VI Line 7a. Essentia Health has reserved powers with respect to Clearwater Valley Hospital and Clinics, Inc. as described in Schedule O Part VI Line 7b.
Form 990, Part VI, Line 7a		Member with right to elect governing body: According to its Bylaws, Critical Access Group shall appoint and remove Clearwater Valley Hospital and Clinics, Inc. governing body.
Form 990, Part VI, Line 7b		Clearwater Valley Hospital and Clinics, Inc. is a subsidiary of Essentia Health, whose Board of Directors has reserved powers with respect to this corporation and its subsidiaries, and all of the other direct and indirect subsidiaries of Essentia Health (collectively, the "System"). Essentia Health's reserved powers are as follows: Strategic and Business Plans. Authority to create, and to approve, the System's strategic and business plans. Mission. Authority to create, and to approve, the mission, purpose and vision statements for all entities in the System by the affirmative vote of at least 67% of the Essentia Health board of directors. Debt. Approval of the incurrence of debt by, and the creation of all mortgages, liens, security interests, or other encumbrances on the assets of, all entities in the System in excess of the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors, and the authority to cause all entities in the System to participate in System borrowing. Governing Instruments. Authority to cause, and to approve, amendments of the articles of incorporation and bylaws of all entities in the System. Mergers and Acquisitions. Authority to cause, and to approve, all mergers, consolidations, and dissolutions of all entities in the System. Affiliations and Joint Ventures. Authority to cause, and to approve, all affiliations, joint ventures and other alliances with third parties of all entities in the System. Transfer of Assets Within the System. Authority to transfer assets, including cash, between and among entities within the System; provided, however, that Essentia Health shall not have authority to require any entity in the System to transfer assets (a) that would cause such entity to be in default of its covenants or obligations under any bond or other financing documents; (b) from the Catholic entities to the secular entities or from the secular entities to the Catholic entities in a manner or to an extent that would cause the Catholic entities to be in violation of the Ethical and Religious Directives for Catholic Health Care Services in the judgment of the local ordinary; or (c) such that money generated by services at secular facilities within the System by procedures that are contrary to the Ethical and Religious Directives for Catholic Health Care Services would be used at the Catholic entities or money generated by Catholic entities would be used in the providing of services contrary to the Ethical and Religious Directives for Catholic Health Care Services at secular facilities within the System. Transfer of Assets Outside the System. Authority to cause, and to approve, the sale, lease or other transfer of assets of all entities in the System to parties outside of the System when the asset's value exceeds the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors. Services. Authority to cause, and to approve, the addition of new services and service locations and the discontinuance of services and service locations within all entities in the System. Budgets. Approval of capital and operating budgets of all entities in the System. Professional Services. Selection of the general legal counsel and external auditors of all entities in the System. Acquisitions. Authority to cause, and to approve, all acquisitions by and formations of entities in the System. Marketing. Authority to implement System-wide marketing and promotional activities. Compliance Plans. Authority to create, and to approve, corporate compliance, safety and risk management plans for entities within the System. Quality Plan. Authority to create, and to approve, the System's quality plan. Non-Budgeted Purchases. Approval of non-budgeted capital purchases and leases in excess of the single or annual aggregate dollar limits prescribed in writing by Essentia Health for entities within the System. Human Resources. Authority to create human resource policies and procedures within the System. Reserved Powers. Authority to create additional Essentia Health reserved powers by the affirmative vote of at least 80% of the Essentia Health board of directors (excluding the Essentia Health CEO); provided, however, that any additional Essentia Health reserved powers shall not contravene or hinder the reserved powers of Benedictine Sisters Benevolent Association.
Form 990, Part VI, Line 11a		Form 990 review process: The 2011 Form 990 including all schedules was reviewed by Clearwater Valley Hospital and Clinics, Inc.'S management and governing body on MAY 7, 2013 prior to filing with the Internal Revenue Service. Each current director of the governing body received a final copy of the 2011 Form 990. Clearwater Valley Hospital and Clinics, Inc.'s Interim President/Chief Financial Officer led the review of the form and schedules and any questions were discussed.
Form 990, Part VI, Line 12c		Practices for monitoring and enforcing Conflict of Interest policy: Interested persons annually disclose relationships which might lead to a conflict of interest by completing a conflict of interest disclosure form. Interested persons include any person in a position to exercise substantial influence over the organization. It includes but is not limited to any director, officer, management, employee, or committee member of Essentia Health or any of its affiliates. Essentia is responsible for the annual distribution of conflict of interest forms and review of disclosures for the governing bodies of Essentia and Essentia Operating Members and for senior management employees of Essentia. Transactions with parties with whom a conflict of interest exists may be undertaken only if all of the following are observed: the conflict of interest is fully disclosed; the interested person with the conflict of interest doesn't participate in the approval of such transactions; if practical or appropriate, a competitive bid or comparable valuation is obtained; and the board or committee of the board has determined that the transaction is in the best interest of the organization. Disclosure by any interested person other than a board or committee member should be made to the Chief Executive Officer (or if she/he is the one with the conflict, then to the board chair), who will bring the matter to the attention of the board or an appropriate committee of the board. Disclosure involving board or committee members should be made to the board chair (or if she/he is the one with the conflict, then to the board vice chair), who will bring these matters to the board or an appropriate committee of the board. The board or committee of the board will determine whether a conflict exists and if so, whether the contemplated transaction may be authorized as just, fair, and reasonable to Essentia or its affiliate(s). The decision of the board or a duly constituted committee of the board on these matters will be at its sole discretion, and its concern must be the welfare of Essentia and its affiliate(s) and the advancement of its purposes. The decision of the board is final. If the board determines a conflict does not exist, the interested person may proceed with the transaction; however, he/she will not be eligible to vote on related issues should they arise. If the board determines a conflict does exist, the interested person will be notified of the decision regarding whether the contemplated transaction will be authorized as just, fair, and reasonable.
Form 990, Part VI, Line 15 A		Process for determining President's compensation: As an employee of Critical Access Group, Clearwater Valley Hospital and Clinics, Inc's President's compensation is reviewed and approved by the CRITICAL ACCESS GROUP's Compensation Committee. The purpose of the CRITICAL ACCESS GROUP Compensation Committee (the "Committee") is to determine the reasonableness of and approve the compensation of CRITICAL ACCESS GROUP executives consistent with the CRITICAL ACCESS GROUP and Essentia Health compensation philosophy. The philosophy is to insure that the organization is able to attract, retain and motivate employees as well as provide the opportunity for adjustments to compensation based upon performance. The Committee will consist of members of the CRITICAL ACCESS GROUP Board of Directors who are not CRITICAL ACCESS GROUP employees. The compensation review will include all benefits paid to the CRITICAL ACCESS GROUP executives. The CRITICAL ACCESS GROUP executives to be reviewed will include all senior/executive vice presidents, all vice presidents, all directors and all CRITICAL ACCESS GROUP facility administrators/CEOs. The CRITICAL ACCESS GROUP CEO and CFO compensation will be reviewed and approved by the Essentia Health Board of Directors Compensation Committee. The Committee will meet at least annually to determine the reasonableness of executive compensation as proposed by CRITICAL ACCESS GROUP management consistent with the CRITICAL ACCESS GROUP compensation philosophy and to approve the proposed compensation. CRITICAL ACCESS GROUP management (HR) will (i) monitor trends in the marketplace on an annual basis and, when appropriate, make recommendations to the Committee regarding overall salary range adjustments prior to the annual budgeting process; and (ii) review the market competitiveness of all CRITICAL ACCESS GROUP executive positions at least once every two years. Prior to making its determination, the Committee will obtain and rely upon appropriate data as to comparability. CRITICAL ACCESS GROUP will contract with an outside third party to conduct market pricing analysis for the CRITICAL ACCESS GROUP executives as well as salary range development. The Committee will adequately document the basis for its determination concurrently with making that determination. The Committee minutes will include: A.The terms of the approved compensation and the date approved; B.The Committee members present during the review, discussion and approval of the proposed compensation and those who voted on the proposed compensation; C.Identification of the comparability data obtained and relied upon by the Committee and how the data was obtained; D.Any actions by a Committee member having a conflict of interest; and E.Documentation of the basis for the determination before the later of the next meeting of the CRITICAL ACCESS GROUP Board of Directors or sixty (60) days after the final actions of the Committee are taken. The CRITICAL ACCESS GROUP Board of Directors will approve the minutes as reasonable, accurate and complete within a reasonable time thereafter The year this process was last undertaken for Clearwater Valley Hospital and Clinics, Inc's President was 2009.
Form 990, Part VI, Line 19		Availability of governing documents, conflict of interest policy, and financial statements to the public: Clearwater Valley Hospital and Clinics, Inc. makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Clearwater Valley Hospital and Clinics, Inc. is part of Essentia Health's consolidated financial statements which are included in Essentia Health's annual report posted on Essentia Health's web site.
Form 990, Part VII Section A, Line 1a, Column B		Hours devoted to related organizations: The following individuals listed in Form 990, Part VII, Section A, Line 1a also devoted time each week to related organizations: Gordon Harman: approximately 1 hour Marjorie Kuchynka: approximately 1 hour Maurice Masar, MD: approximately 1 hour Larry Coonts: approximately 1 hour Gary Rehder: approximately 1 hour Dan Davis: approximately 6 hours Sister Mary Rochefort: approximately 1 hour Sister Barbara Jean Glodowski: approximately 1 hour Bryan Higgins: approximately 1 hour Lee Pippenger: approximately 1 hour Lonnie Simpson: approximately 1 hour Henry Clay: approximately 1 hour Michael Hedrix is employed by Critical Access Group as Critical Access Group Senior Vice President of Operations. 100% of his time is spent furthering the purpose of Critical Access Group and related organizations. Kelly McGrath, MD is employed by of Clearwater Valley Hospital and Clinics, Inc. 100% of his time is spent furthering the purpose of Clearwater Valley Hospital and Clinics, Inc. and St. Mary's Hospital & Clinics, Inc. Alvin Secrest III, MD is employed by St. Mary's Hospital & Clinics, Inc. 100% of his time is spent furthering the purpose of Clearwater Valley Hospital and Clinics, Inc. and St. Mary's Hospital & Clinics, Inc. Andrew Gilbert, MD is employed by St. Mary's Hospital & Clinics, Inc. 100% of his time is spent furthering the purpose of Clearwater Valley Hospital and Clinics, Inc. and St. Mary's Hospital & Clinics, Inc. Colleen Meza is employed by Critical Access Group as Clearwater Valley Hospital and Clinics, Inc.'s and St. Mary's Hospital & Clinics, Inc.'s President. 100% of her time is spent furthering the purpose of Clearwater Valley Hospital and Clinics, Inc. and St. Mary's Hospital & Clinics, Inc. Lenne Bonner is employed by Clearwater Valley Hospital and Clinics, Inc. as Clearwater Valley Hospital and Clinics, Inc.'s and St. Mary's Hospital & Clinics, Inc.'s Chief Financial Officer. 100% of her time is spent furthering the purpose of Clearwater Valley Hospital and Clinics, Inc. and St. Mary's Hospital & Clinics, Inc.
Form 990, Part XI, Line 5		Other Changes in Net Assets: The total amount of other changes in net assets includes: Unrealized loss on trading securities: ($55,320)
Form 990, Part XII, Line 3		Consolidated A-133: Clearwater Hospital & Clinics, Inc., as part of Essentia Health's consolidated financial statements, was required and underwent a consolidated audit set forth in the Single Audit Act and OMB Circular A-133. The consolidated audit is reviewed by the Essentia Health Audit Committee.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

Clearwater Valley Hospital and Clinics Inc

Employer identification number

82-0497771

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
(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	Yes	No
(1) Brainerd Lakes Integrated Health System 2024 S 6th St Brainerd,MN56401 37-1532145	SUPPORT ORG	MN	501(c)(3)	11 II	ESSENTIA	Yes
(2) Brainerd Medical Center Inc 2024 S 6th St Brainerd,MN56401 37-1532148	Clinic	MN	501(c)(3	3	BLIHS	Yes
(3) Bridges Medical Center 201 9th St W Ada,MN56510 20-0479568	Clinic/Hosp	MN	501(C)(3)	3	INNOVIS	Yes
(4) Divine Medical Services THRU 10111 709 N Lincoln Jerome,ID83338 20-2773717	Emerg SrvCS	ID	501(C)(3)	3	SBFMC	Yes
(5) DL Surgery Center 1027 Washington Ave Detroit Lakes,MN56501 26-3837203	ASC	MN	501(C)(3)	3	CAG	Yes
(6) CRITICAL ACCESS GROUP 503 E 3rd ST Ste 400 Duluth,MN55805 26-1219624	Support ORG	MN	501(C)(3)	11 II	Essentia	Yes
(7) St Benedict's Fam Med CNTR THRU 10111 709 N Lincoln Jerome,ID83338 82-0227163	Clinic/Hosp	ID	501(C)(3)	3	CAG	Yes
(8) St Joseph's Medical Center 523 N 3rd St Brainerd,MN56401 41-0695602	CLINIC/HOSP	MN	501(C)(3)	3	BLIHS	Yes
(9) St Mary's EMS 1027 Washington Ave Detroit Lakes,MN56501 41-1805811	Emerg SrvCS	MN	501(C)(3)	9	SMRHC	Yes
(10) St Mary's Hospital & Clinics Inc PO Box 137 Cottonwood,ID83522 82-0226453	Clinic/Hosp	ID	501(C)(3)	3	CAG	Yes
(11) St Mary's Innovis Health 1027 Washington Ave Detroit Lakes,MN56501 26-2861321	Clinic	MN	501(C)(3)	3	INNOVIS	Yes
(12) St Mary's Regional Health Center 1027 Washington Ave Detroit Lakes,MN56501 41-1620386	Clinic/Hosp	MN	501(C)(3)	3	INNOVIS	Yes
(13) Essentia Health 502 E 2nd St Duluth,MN55805 20-0360007	Support ORG	MN	501(C)(3)	11 III-FI	NA		No
(14) Innovis Health LLC 3000 32nd Ave Fargo,ND58103 26-1175213	Clinic/Hosp	DE	501(C)(3)	3	Essentia	Yes
(15) Midwest Medical Equipment & Supply Inc 4418 Haines Rd Duluth,MN55811 41-1674021	Medical Equip	MN	501(C)(3)	9	SMMC	Yes
(16) SMDC Medical Center 502 E 2nd St Duluth,MN55805 41-1878730	Clinic/Hosp	MN	501(C)(3)	3	SMDCHS	Yes
(17) Pine Medical Center 109 Court Ave S Sandstone,MN55072 41-1884597	HOSPITAL/NURS	MN	501(C)(3)	3	SMDCHS	Yes
(18) Polinsky Medical Rehabilitation Center 530 E 2nd St Duluth,MN55805 41-0691275	Clinic	MN	501(C)(3)	3	SMMC	Yes
(19) St Mary's Duluth Clinic Health System 407 E 3rd St Duluth,MN55805 41-1836633	SUPPORT ORG	MN	501(C)(3)	11 II	Essentia	Yes
(20) St Mary's HoSpital of Superior 3500 Tower Ave Superior,WI54880 41-1811073	Clinic/Hosp	WI	501(C)(3)	3	SMMC	Yes
(21) St Mary's Medical Center 407 E 3rd St Duluth,MN55805 41-0695604	HOSPITAL	MN	501(C)(3)	3	SMDCHS	Yes
(22) The Duluth Clinic Ltd 400 E 3rd St Duluth,MN55805 41-0883623	Clinic	MN	501(C)(3)	3	SMDCHS	Yes
(23) First Care Medical Services 900 Hilligross Blvd SE Fosston,MN56542 41-0706143	Clinic/Hosp	MN	501(C)(3)	3	INNOVIS	Yes
(24) Minnesota Valley Health Center 621 S 4th St Le Sueur,MN56058 41-0837659	Hospital/NURS	MN	501(C)(3)	3	CAG	Yes
(25) Essentia Institute of Rural Health 502 E 2nd St Duluth,MN55805 27-1291124	Research	MN	501(C)(3)	4	Essentia	Yes
(26) ESSENTIA Health Foundation 502 E 2nd St Duluth,MN55805 27-1984704	Foundation	MN	501(C)(3)	7	ESSENTIA	Yes
(27) NORTHERN PINES MEDICAL CENTER 5211 HWY 110 AURORA,MN55705 41-0841441	HOSPITAL/NURS	MN	501(C)(3)	3	SMDCHS	Yes
(28) GRACEVILLE HEALTH CENTER 115 WEST SECOND ST GRACEVILLE,MN56240 41-0726173	CLINIC/HOSP	MN	501(C)(3)	3	INNOVIS	Yes

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2011

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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) PMC-Gateway Imaging LLC 109 Court Ave S Sandstone,MN55072 26-1634764	Imaging ServiCES	MN	NA	N/A	0	0			0			0 %

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
(1) Essentia Health Insurance Services SPC Buckingham Sq 720 W Bay Rd PO 69 Grand Cayman,Cayman IslandsKY1-1102 CJ 000000000	Insurance	CJ	NA	Foreign Corp	0	0	0 %
(2) East Range Clinics LTD 910 6th Ave N Virginia,MN55792 41-0909915	Clinics	MN	NA	C CORP	0	0	0 %

Schedule R (Form 990) 2011

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

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 . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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) St Mary's Hospital & Clinics Inc	n	1,338,822	ACTUAL COSTS
(2) St Mary's Hospital & Clinics Inc	P	1,049,910	ACTUAL COSTS
(3) St Mary's Hospital & Clinics Inc	O	1,016,482	ACTUAL COSTS
(4) St Mary's Hospital & Clinics Inc	Q	500,000	ACTUAL COSTS
(5) St Mary's Hospital & Clinics Inc	e	500,000	ACTUAL COSTS
(6) Critical Access Group	L	431,436	ACTUAL COSTS
(7) Critical Access Group	O	1,377,069	ACTUAL COSTS
(8) Essentia Health	o	256,485	ACTUAL COSTS

Schedule R (Form 990) 2011

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)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2011

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
Schedule R, Part II, Column (a)		Name: In 2011, many Essentia entities adopted a doing business as name as part of a system-wide rebranding strategy using the Essentia brand. Legal Name; Doing Business As Name Brainerd Lakes Integrated Health System; Essentia Health Central Brainerd Medical Center, Inc.; Essentia Health Brainerd Specialty Clinic Bridges Medical Center; Essentia Health Ada First Care Medical Services; Essentia Health Fosston Graceville Health Center; Essentia Health Holy Trinity Hospital Innovis Health, LLC; Essentia Health West Midwest Medical Equipment & Supply Inc.; Essentia Health Medical Equipment and Supplies Northern Pines Medical Center; Essentia Health Northern Pines Pine Medical Center; Essentia Health Sandstone Polinsky Medical Rehabilitation Center; Essentia Health Polinsky Medical Rehabilitation Center SMDC Medical Center; Essentia Health Duluth St. Joseph's Medical Center; Essentia Health St. Joseph's Medical Center St. Mary's Duluth Clinic Health System; Essentia Health East St. Mary's Hospital of Superior; Essentia Health St. Mary's Hospital-Superior St. Mary's Medical Center; Essentia Health St. Mary's Medical Center St. Mary's Regional Health Center; Essentia Health St. Mary's-Detroit Lakes

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: We are called to make a healthy difference in people's lives.
2	Check this box
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	8
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	231
6	Total number of volunteers (estimate if necessary) ....	6	87
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	251,504	267,243
9	Program service revenue (Part VIII, line 2g) .........	19,349,804	19,376,156
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	82,495	13,771
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	39,283	31,183
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	19,723,086	19,688,353
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	1,050	1,575
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)	11,876,421	11,651,680
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 71,212
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	7,303,147	7,486,925
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	19,180,618	19,140,180
19	Revenue less expenses. Subtract line 18 from line 12.......	542,468	548,173
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	9,269,376	9,804,145
21	Total liabilities (Part X, line 26).............	3,030,670	3,072,586
22	Net assets or fund balances. Subtract line 21 from line 20.....	6,238,706	6,731,559

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 16,168,071 including grants of $ 1,575 ) (Revenue $ 19,376,156 )
	See schedule O

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 expenses$ 16,168,071

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)				(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
(A) Name and Title
(18) Lenne Bonner Chief Financial Officer	50.0	X			135,865	0	32,036
(19) Clayton Bunt MD Physician	40.0		X		203,561	0	31,065
(20) Michael Meza MD Physician	40.0		X		216,991	0	34,321
(21) Enrique Montana MD Surgeon	40.0		X		256,914	0	27,501
(22) VANESSA BROWN MD PHYSICIAN	40.0		X		188,858	0	17,828
(23) PHILLIP PETERSEN MD PHYSICIAN	40.0		X		178,955	0	32,392
(24) Larry Barker Chief Operating Officer	40.0			X	107,235	0	25,639

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,502,083	1,114,105	446,504

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		113,036

f	All other contributions, gifts, grants, and similar amounts not included above1f		154,207
g	Noncash contributions included in lines 1a-1f:$ 60,000
h	Total. Add lines 1a-1f.......			267,243
			Business Code
2a	HOSPITAL & CLINIC SERVICES		621,110	19,376,156	19,376,156
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			19,376,156
3	Investment income (including dividends, interest
	and other similar amounts).....			15,420			15,420
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		67,181
b	Less: cost or other basis and sales expenses	-4,799	64,031
c	Gain or (loss)	4,799	3,150
d	Net gain or (loss)..........			-1,649			-1,649
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..			0
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...			0
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..			0
Miscellaneous Revenue			Business Code
11a	VENDING SALES		722,210	12,314			12,314
b	MEDICAL RECORD COPIES		561,439	9,974			9,974
c	FITNESS DUES		713,940	8,895			8,895
d	All other revenue ....
e	Total. Add lines 11a–11d ......			31,183
12	Total revenue. See Instructions....			19,688,353	19,376,156		44,954


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			425	1	725
2	Savings and temporary cash investments .......			1,058,997	2	2,075,777
3	Pledges and grants receivable, net .........			73,869	3	84,635
4	Accounts receivable, net .........			3,970,612	4	3,629,626
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........			0	5	0
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 ..........			0	6	0
7	Notes and loans receivable, net .............			34,000	7	15,000
8	Inventories for sale or use ..............			488,953	8	420,413
9	Prepaid expenses and deferred charges ............			63,639	9	69,581
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	6,716,947
b	Less: accumulated depreciation. .....	10b	3,652,562	2,430,857	10c	3,064,385
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 ......			1,148,024	12	444,003
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets .........			0	14	0
15	Other assets. See Part IV, line 11 ...........			0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)...			9,269,376	16	9,804,145
17	Accounts payable and accrued expenses .			1,733,992	17	1,784,673
18	Grants payable ..........			0	18	0
19	Deferred revenue ..........			0	19	0
20	Tax-exempt bond liabilities ..........			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			111,801	23	126,510
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			1,184,877	25	1,161,403
26	Total liabilities. Add lines 17 through 25.....			3,030,670	26	3,072,586
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			6,238,706	27	6,731,559
28	Temporarily restricted net assets .....			0	28	0
29	Permanently restricted net assets .....			0	29	0
	Organizations that do not follow SFAS 117, check here 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 .....			6,238,706	33	6,731,559
34	Total liabilities and net assets/fund balances .....			9,269,376	34	9,804,145