TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(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) JAMES PILLEN DVM........................................................................ CHAIR	1.0 .......................0.0	X	X		0	0
(2) ANTHONY RAIMONDO JR........................................................................ TREASURER	1.0 .......................0.0	X	X		0	0
(3) JEFFREY GOTSCHALL MD........................................................................ VICE CHAIR	1.0 .......................0.0	X	X		0	0
(4) RONALD ERNST MD........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(5) JOHN C MCCLURE........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(6) REBECCA RAYmond........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(7) BONNIE MCPHILLIPS........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(8) BRIAN SCHMIDT........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(9) CLARK LEHR........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(10) BETH PRZYMUS........................................................................ DIRECTOR	1.0 .......................0.0	X			0	0
(11) MARK HOWERTER MD........................................................................ DIRECTOR/PHYSICIAN	40.0 .......................0.0	X			430,238	17,254
(12) MICHAEL HANSEN........................................................................ PRESIDENT/CEO/SECRETARY	39.0 .......................1.0		X		285,748	15,096
(13) AMY BLASER........................................................................ VP BUSINESS DEVELOPMENT	40.0 .......................0.0		X		117,753	12,122
(14) J JOSEPH BARBAGLIA........................................................................ VP FINANCE	40.0 .......................0.0		X		206,436	18,584
(15) LINDA WALLINE........................................................................ VP NURSING	40.0 .......................0.0		X		177,977	16,505
(16) JAMES GOULET........................................................................ VP OPERATIONS	40.0 .......................0.0		X		174,841	19,653
(17) ROBERT MILLER MD........................................................................ PHYSICIAN	40.0 .......................0.0			X	232,484	15,626

(A) Name and business address	(B) Description of services	(C) Compensation
INPATIENT PHYSICIAN ASSOC, 3200 PINE LAKE RD STE ALINCOLNNE68516	HOSPITALIST SVCS	819,497
FOCUSONE SOLUTIONS LLC, 13609 California St 300OMAHANE68154	STAFFING AGENCY	201,879
TSP CONSTRUCTION SERVICES INC, 1112 N WEST AVESIOUX FALLSSD571041333	CONSTRUCTION SVCS	1,743,118
SUNQUEST INFORMATION SYSTEMS, 250 South Williams BlvdTUCSONAZ85711	IT SERVICES	151,341
MCKESSON TECHNOLOGIES INC, PO Box 98347CHICAGOIL60693	IT Consulting	1,265,326
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 9

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	65,781	65,781
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	1,403,561	1,403,561
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 ....	962,755		962,755
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	27,012,666	27,012,666
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	920,503	920,503
9	Other employee benefits .......	3,101,733	3,101,733
10	Payroll taxes ...........	1,908,119	1,908,119
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	72,106		72,106
c	Accounting ...........	163,123		163,123
d	Lobbying ...........	5,786		5,786
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	2,713,479	2,713,479
12	Advertising and promotion ....	188,284		188,284
13	Office expenses .......	9,060,357	8,811,024	249,333
14	Information technology ......	1,420,413	1,420,413
15	Royalties ..	0
16	Occupancy ...........	1,151,503	1,151,503
17	Travel ............	192,992		192,992
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	99,584		99,584
20	Interest ...........	216,286	216,286
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	5,341,079	5,341,079
23	Insurance ..............	259,560	259,560
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	PROVISION FOR BAD DEBTS	3,963,281	3,963,281
b	MINOR EQUIP. & FINANCING AGRMT	2,027,258	2,027,258
c	PURCHASED SERVICES	1,290,364	1,290,364
d	RECRUITING	282,795	282,795
e	All other expenses	1,333,677	1,333,677
25	Total functional expenses. Add lines 1 through 24e	65,157,045	63,223,082	1,933,963	0
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 Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	5,507,494	1	1,933,467
2	Savings and temporary cash investments .........	0	2	0
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	8,997,202	4	9,233,671
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	1,454,475	8	1,077,673
9	Prepaid expenses and deferred charges ..........	1,418,337	9	1,512,950
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	86,726,440
b	Less: accumulated depreciation .....	10b	49,024,725	37,861,816	10c	37,701,715
11	Investments—publicly traded securities ..........	45,055,102	11	46,218,318
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
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 ...........	312,912	15	214,862
16	Total assets. Add lines 1 through 15 (must equal line 34)......	100,607,338	16	97,892,656
	17	Accounts payable and accrued expenses .........	6,699,617	17	6,956,170
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	11,631,855	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other 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 ..	0	23	0
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....................	0	25	0
26	Total liabilities. Add lines 17 through 25.........	18,331,472	26	6,956,170
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	82,275,866	27	90,936,486
28	Temporarily restricted net assets ...........	0	28	0
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........	82,275,866	33	90,936,486
34	Total liabilities and net assets/fund balances ........	100,607,338	34	97,892,656

- 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

2012

Open to Public
Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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 described in 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. See section 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 - Non-functionally integrated

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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—2011. If the organization did not check a 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—2012. 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—2011. 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) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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—2011. 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) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

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

2012

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization COLUMBUS COMMUNITY HOSPITAL INC

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization COLUMBUS COMMUNITY HOSPITAL INC

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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) (2012)

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

2012

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, Part V, line 35c (Proxy Tax), then
Round Bullet

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

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

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 SchCMd Bullet

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable 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) 2012

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

5,786

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

5,786

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, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
OTHER ACTIVITIES	SCHEDULE C, PART II-B, LINE 1I	DUES PAID TO AMERICAN HOSPITAL ASSOCIATION ALLOCATED TO LOBBYING $3,126 DUES PAID TO NEBRASKA HOSPITAL ASSOCIATION ALLOCATED TO LOBBYING $2,660

Schedule C (Form 990 or 990EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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 section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

Using the organization’s acquisition, 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 XIII.

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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	1,667,736	1,573,063	1,506,660	1,426,826	1,299,402
b	Contributions ........	74,389	94,673	66,403	79,844	127,424
c	Net investment earnings, gains, and losses				-10
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......	1,742,125	1,667,736	1,573,063	1,506,660	1,426,826

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

100.000 %

Temporarily restricted endowment SchDMd Bullet

0 %

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)

Yes

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

Yes

Describe in Part XIII 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 .................	639,544		639,544
b	Buildings ................	43,742,952	18,261,210	25,481,742
c	Leasehold improvements ............
d	Equipment ................	37,107,980	29,053,953	8,054,027
e	Other .................	5,235,964	1,709,562	3,526,402
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				37,701,715

Schedule D (Form 990) 2012

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









Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		0
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI 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 XIII.) ............	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 XIII.) ...........	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 XII 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 XIII.) ............	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 XIII.) ............	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 XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
FIN 48 FOOTNOTE	SCHEDULE D, PART X	The Hospital adopted Financial Accounting Standards Board (FASB) Interpretation No. 48, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No. 109 (FIN 48). FIN 48 provides specific guidance on how to address uncertainty in accounting for income tax assets and liabilities, prescribing recognition thresholds and measurement attributes. The adoption of FIN 48 by Columbus Community Hospital did not have a material impact on the Hospital's financial position, results of operations, or cash flows. In Fiscal Years Ending 2013 and 2012, management determined that there are no income tax positions requiring recognition in the financial statements.
SCHEDULE D	PART V, LINE 4	ENDOWMENT FUNDS ARE HELD AND MAINTAINED BY COLUMBUS COMMUNITY HOSPITAL FOUNDATION. THE ENDOWMENT FUNDS EXIST IN SUPPORT OF IMPROVED HEALTH SERVICES BY COLUMBUS COMMUNITY HOSPITAL.

Schedule D (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

Part I

Financial Assistance 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) as a factor in determining 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 as a factor in determining 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 used factors other than FPG in determining 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, as a factor in determining 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

Financial Assistance and Means-Tested Government Programs		(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) ..	693	745,712		745,712	1.220 %
b	Medicaid (from Worksheet 3, column a) ....		4,065,048	1,387,451	2,677,597	4.380 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	693	4,810,760	1,387,451	3,423,309	5.600 %
Other Benefits		63,565	492,166	1,955	490,211	0.800 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	63,565	492,166	1,955	490,211	0.800 %
f	Health professions education (from Worksheet 5) ..	811	1,218,981	17,111	1,201,870	1.960 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)		1,612		1,612
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	601	11,649		11,649	0.020 %
j	Total. Other Benefits ..	64,977	1,724,408	19,066	1,705,342	2.780 %
k	Total. Add lines 7d and 7j .	65,670	6,535,168	1,406,517	5,128,651	8.380 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

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	1		1,250		1,250
2	Economic development	1	650	2,295		2,295
3	Community support
4	Environmental improvements	1		2,624		2,624
5	Leadership development and training for community members
6	Coalition building	2	3,935	51,909	6,700	45,209	0.070 %
7	Community health improvement advocacy
8	Workforce development	2	799	9,157	600	8,557	0.010 %
9	Other
10	Total	7	5,384	67,235	7,300	59,935	0.080 %

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

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

3,963,281

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

21,114,039

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

22,457,569

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

-1,343,530

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(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(e) Physicians' profit % or stock ownership %
1HEALTHPARK LLC	PROPERTY MANAGEMENT	71.000 %
2ZARZ LLC	PROPERTY MANAGEMENT	50.000 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address					Other (Describe)
1	Columbus Community Hospital INC 4600 38th Street Columbus,NE686011800	X	X	X	47 Bed acute care Hospital w/ 24 HR ER Services

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	COLUMBUS COMMUNITY HOSPITAL INC
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Yes

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	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.
11	Used FPG to determine eligibility for providing discounted care?.................	11	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.
12	Explained the basis for calculating amounts charged to patients?.................	12	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	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?.......	15	Yes
16	Check all of the following 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)
17	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?..........	17		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)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

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?9
Name and address		Type of Facility (describe)
1	PREMIER PHYSICAL THERAPY OF CCH US 30 CTR BLDG 3100-23RD st ste 15 COLUMBUS,NE686013161	PHYSICAL & AQUATIC THERAPY, SPORTS TRAINING SERVICES
2	WIGGLES & GIGGLES THERAPY FOR KIDS 2108-13TH STREET COLUMBUS,NE686015100	PEDIATRIC THERAPY SERVICES
3	OCCUPATIONAL HEALTH SERVICES OF CCH 3005-19TH ST SUITE 300 COLUMBUS,NE686014252	EMP. HEALTH CARE SVCS TO PREVENT & TREAT WORK INJURIES
4	WOUND HEALING CENTER 4600-38TH STREET SUITE 165 COLUMBUS,NE68601	WOUND TREATMENT CENTER
5	HUMPHREY CLINIC OF CCH 3003 MAIN STREET HUMPHREY,NE686423155	CLINIC IN SMALL TOWN TO OFFER MEDICAL SVCS TO RESIDENTS
6	HOSPICE OF COLUMBUS COMMUNITY HOSPITAL 3005-19TH STREET SUITE 600 COLUMBUS,NE686014248	HOSPICE SERVICES
7	COLUMBUS COMMUNITY HOSPITAL SLEEP LAB 3020-19TH STREET SUITE 100 COLUMBUS,NE686014252	POLYSOMNOGRAPHIC SLEEP TESTING
8	HOME HEALTH OF COLUMBUS COMMUNITY HOSP 3005-19TH STREET SUITE 600 COLUMBUS,NE686014248	HOME HEALTH SERVICES
9	COLUMBUS ORTHOPEDIC & SPORTS MED CLINIC 4508 38TH STREET STE 133 COLUMBUS,NE686011668	FREE STANDING CLINIC
10

Schedule H (Form 990) 2012

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; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
PART I, LINE 3C		N/A
PART I, LINE 6A		A Community Benefit report is included each year in the Hospital's quarterly newsletter "Housecall" with an electronic version of the newsletter housed on the Hospital's website. A separate landing page on the website was also created for the report to provide easy access to the report.
PART I, LINE 7		To determine costs associated with Charity Care and Community Benefits costs, the Hospital has used the worksheets offered in the Schedule H instructions. The ratio of patient care costs to charges on Worksheet 2 was used to calculate THE amounts reported on Line 7 of the table. The denominator used to calculate column (F) is the total operating expenses in Part IX, less the bad debt amount of $3,963,281 to arrive to the denomination of $61,193,764.
PART II	COMMUNITY BUILDING ACTIVITIES	-Hospital continues to collaborate with local Chamber of Commerce to recruit skilled professionals to fill job openings in the community. Provides support and staff time to assist in highlighting the health care community, providing specific department or hospital tours in order to recruit skilled professions to live and work here in the community. -Hospital sold land to the City to provide space for a twelve-acre urban lake and 20 acres of land for a future fire station on this property. The urban lake is equipped with a nice wooden dock that makes it very accessible for strollers, wheelchairs and other assistive devices to roll down the dock to fish or watch the waterfowl on the lake. Local assisted living and nursing care centers bring their wheel chair vans with residents to the lake as they can drive right up to the accessible dock. This urban lake, waterfowl area provides a community space within the city limits for the whole community, young and old alike. -Hospital continues to partner in several projects and community disease prevention initiatives with our local District Public Health Department and Community Health Center (CHC). The hospital provides financial support and much professional staff time as liaisons to these community partnerships throughout the year working on multiple chronic disease and accident prevention strategies. Some of these community initiatives include type II diabetes, hypertension and heart disease, pre and post natal newborn care, physical activity and exercise, colon cancer prevention and early detection as well as community preparedness to natural and manmade disasters. Several other initiatives are addressed throughout the year as community health issues arise. Thousands of community members are reached with these community initiative campaigns each year and these make a real difference in people's lives that are living with chronic health issues. WE PROVIDE FREE FLU SHOTS TO RESIDENTS OF HARBOR OF HOPE, A HOMELESS SHELTER. -Additionally CCH is in attendance in over a dozen Community Health Fairs/Community events each year, providing medical screenings and information for all community members. -CCH also partners with local day cares, schools and colleges to provide speakers and hands on learning events for students to encourage entry into the medical professions.
PART III, LINE 4		Financial statements do not include any text for bad debt. The amount in Line 2 is the book bad debt amount. Charity care is kept separate from bad debt.
PART III, LINE 8		In accordance with 42 CFR 413.24, Columbus Community Hospital uses the "Step-down Method" as its costing methodology. Departments within a provider are usually divided into two types: 1) Those that produce patient care revenue (e.g., routine services, radiology), and 2) Those that do not directly generate patient care revenue but are utilized as a service by other departments (e.g., laundry and linen, dietary). The two types of departments are commonly referred to as "revenue-producing cost centers" and "nonrevenue-producing cost centers," respectively. Although nonrevenue-producing cost centers do not directly produce patient care revenue, they contribute indirectly to patient care revenue generated by "serving" as a service to the revenue-producing centers and also to other nonrevenue-producing centers. Therefore, for the purpose of proper matching of revenue and expenses, the cost of the revenue-producing centers should include both its direct expenses and its proportionate share of the costs of each nonrevenue-producing center (indirect costs) based on the amount of services received. The process of allocating the cost of a particular nonrevenue-producing center to other nonrevenue-producing centers and revenue-producing centers is performed by utilizing a set of statistics (e.g., pounds of laundry for allocating "laundry and linen" costs, square feet for allocating "depreciation building" costs). Every nonrevenue-producing cost center has the potential of being allocated to every other nonrevenue-producing cost center in addition to the revenue-producing cost centers. This precludes a simple allocation of the direct expense of the nonrevenue-producing cost center because the indirect costs derived from allocation of other nonrevenue-producing cost centers must be computed in determining the "full cost" (direct and indirect costs) of the nonrevenue-producing cost center being allocated. The "Step-down Method" recognizes that services furnished by certain nonrevenue-producing departments are utilized by certain other nonrevenue-producing centers as well as by the revenue-producing centers. All costs of nonrevenue-producing centers are allocated to all centers that they serve, regardless of whether or not these centers produce revenue. The cost of the nonrevenue-producing center serving the greatest number of other centers, while receiving benefits from the least number of centers, is apportioned first. Following the apportionment of the cost of the nonrevenue-producing center, that center will be considered "closed" and no further costs are apportioned to that center. This applies even though it may have received some service from a center whose cost is apportioned later. Generally, if two centers furnish services to an equal number of centers while receiving benefits from an equal number, that center which has the greatest amount of expense should be allocated first.
PART III, LINE 9B		CHARITY (FINANCIAL AID) PROGRAM POLICY/PROCEDURE Columbus Community Hospital (CCH) offers a Charity/Financial Aid Program to provide uncompensated services to people who are unable to pay. CCH Charity/Financial Aid Policy reflects the mission, vision and values of CCH. It is intended to assist low-income, underinsured, and uninsured individuals whose financial status, under the hospital's qualification criteria, makes it impractical or impossible to pay for necessary medical services. CCH has a fiduciary responsibility to seek payment for services from those who can pay, and every effort will be made to apply consistent, fair and equitable financial aid practices in a manner consistent with all applicable federal and state laws and regulations. 1. Charity Policy a. Our Charity/Financial Aid Policy does not eliminate the personal responsibility and financial discounts are always secondary to other government-sponsored programs. However, CCH is committed to serve those without the means to pay and work with Good Neighbor Community Health Center and Medicaid services. 2. Health Insurance a. If a patient or guarantor has access to employer-based or government-sponsored health insurance, yet elected not to enroll or failed to maintain eligibility, they may be considered. They will be encouraged to obtain coverage at the next eligible period. b. If patient or guarantor has a Medical Savings Account, this needs to be expended before they are eligible for assistance. c. "Presumptive" financial assistance may be taken into consideration when a patient has expired and there is no estate. An incomplete financial assistance form may be on file because documentation was lacking that would support the provision of financial aid. In this case: i. A family member is contacted to insure no estate exits. ii. Family member may be asked to sign and date a statement to the effect that no estate exits. iii. The county in which the deceased patient resided is contacted to verify that no estate exits. d. CCH's Charity/Financial Aid is not a substitute for employer-sponsored, public or individually-purchased insurance, nor is CCH's financial aid policy a substitute for the responsibility of government and employers to expand access to health care coverage for all persons. 3. Accounts with a Balance a. Charity/Financial Aid may apply to balances due from insured patients for deductibles, co-payments, or co-insurance, or other types of patient payment responsibility. 4. Receiving an application a. CCH is diligent in its efforts to determine, at the earliest point in time, the patient's ability to pay. Information on Charity/Financial Assistance is available in key areas of the hospital on how to apply or obtain further information, as well as hospital website and patient statements. i. Hospital staff members who work closely with patients are educated on how to communicate financial aid availability and how to direct patients to staff responsible for the financial aid application process. ii. Staff members are trained to treat financial aid applicants with courtesy, confidentiality, and cultural sensitivity. iii. These principles and guidelines are for those patients who truly cannot afford health care services. b. Any person requesting financial aid information will be directed to the Patient Accounts or Social Services Departments. An application for the Charity/Financial Aid Program needs to be completed before an eligibility determination can be made. The application is also available in Spanish. Once the application is submitted with written proof of income, a determination will be made in a timely manner. One or more of the following are required as verification of income: i. A letter of rejection from the Department of Social Services (Medicaid) if applicable. ii. Signed copy of previous year's tax return. iii. Copy of most recent pay stub, with accumulative earnings. iv. Copy of recent three months of bank statements with an explanation of all deposits. v. Copy of any compensation received, i.e., unemployment, if applicable. vi. Social Security determination if applicable. c. A family is defined as anyone living together in a household; this will include college students, regardless of their residence, who are supported by their parents. 5. Review Process a. All completed applications are reviewed and approved by the Patient Financial Services Director and overseen by the Vice-President of Finance. b. Any applications that are in need of further assistance are taken to the Vice-President of Finance. c. All write-offs greater than $5,000 are reviewed by Vice President of Finance. d. Monthly the Vice-President of Finance oversees the Charity and Medicare Bad Debt statistical reports. e. If the applicant's income is above Poverty Guidelines, but is still in need of assistance, a sliding scale will be used. This scale is adjusted according to the current year's Poverty Guidelines. If the applicant qualifies for partial Charity/Financial Assistance, acceptable monthly payment arrangements must be agreed upon. f. If the applicant qualifies for partial Charity/Financial Assistance and the total balance after all write-off's is $1,200 or greater, an additional write-off will be done as outlined below. Reduce to $1,200, Adjustments will be done from oldest to newest. g. A letter will be sent to the Guarantor informing them of the determination for charity/financial assistance along with a Monthly Payment Agreement for those who qualified for partial approval or denied applicants. This Agreement needs to be signed and returned to the Patient Accounts Department within 10 days. 6. Documentation of Processed Accounts a. The Patient Financial Services Director will maintain a yearly log of all applicants. Documentation of approved accounts that have been written off or denied will be maintained. 7. Archived Applications a. All charity applications are scanned into HBF under Document Type 'Charity Applications' Part V, Section B, Line 3 Mobilizing for Action through Planning and Partnership (MAPP) process was developed by and is recommended for community assessment by the National Association of City and County Health Officials (NACCHO) and Center for Disease Control (CDC). MAPP was also a recommended community assessment by the Nebraska Rural Health Association in its "Community Health Assessment Collaborative Preliminary recommendations for Nebraska's community, nonprofit hospitals to comply with new requirements for tax exempt status enacted by the Patient Protection and Affordable Care Act" (September of 2011). MAPP was chosen in part because the process allows for input from parties who represent broad interests in the communities. Input from diverse sectors including medically underserved, low-income, minority populations and individuals from diverse age groups was obtained through surveys, targeted focus groups, open public meetings and target invitations to community leaders and agencies. The current MAPP assessment that CCH is involved with is the most thorough assessment to date with the most participation having over 100 individuals participate in the process to date from the district, this does not count the 1,000 individuals surveyed or the participants in focus groups. Part V, Section B, Line 4 -Alegent Health Memorial Hospital, Schuyler -Genoa Community Hospital -Boone County Health Center Part V, Section B, Line 5c THE DETAILED ASSESSMENT AND RELATED COMPONENTS ARE AVAILABLE VIA LINK ON http://www.columbushosp.org/news_events/community_health_needs_assessment_ chna.aspx; AVAILABLE ON REQUEST AND AVAILABLE FOR REVIEW AT Columbus Community Hospital. THE IMPLEMENTATION STRATEGY IS AVAILABLE VIA LINK ON http://www.columbushosp.org/news_events/chip_implementation_plan.aspx. Part V, Section B, Line 7 IDENTIFY THE PRIORITIES FOR AREAS THAT WE ARE NOT DIRECTLY ADDRESSING BUT THAT WE WILL MAINTAIN ACTIVE PARTNERSHIPS WITH AND REMAIN SUPPORTIVE OF THE LEAD ORGANIZATIONS FOCUSED ON THESE PRIORITIES.
NEEDS ASSESSMENT		In 2010, the Columbus community Hospital's five year strategic plan was implemented. The plan includes a thorough assessment of the organization's external environment in terms of opportunities and threats in order to determine its internal strengths and weaknesses. The plan also includes strategic issues, goals, and related strategies for future organizational effectiveness. Six Organizational Pillars were identified: quality, culture, people, service, facilities, and finance. 1) Quality - Quality efforts have been focused on evidence based processes and educating staff on the importance of use and integration into daily operations. Cch has implemented an electronic medical record to afford ease of information access and communication across the continuum of care. 2) Culture - In AN effort to achieve a high performance organization, cch is in the process of implementing a 4-part culture improvement initiative including teamstepps, just culture, studer, and lean/six sigma process improvement. A 3-year implementation time frame has been established. 3) People - CCH has continued to employ aggressive employee and physician recruitment efforts to attract and retain the workforce needed to support strategic growth initiatives across all service lines. 4) Services - cch performs annual, comprehensive program review of existing and new services and has ranked priority to begin service line development in areas such as hospital medicine, orthopedics, cardiology, cancer, and rehab services. 5) Facilities - CCH has developed a comprehensive master facilities plan that is able to adapt to current and future patient care needs. An emergency department expansion was completed in 2012.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE		Here is a sample of what is available on our CCH Web Site with detailed links as well as hard copy information in a special wall unit located inside each patient room as well as outpatient areas in brochures. There is also a tutorial listed for each step of the way letting the patient know what they will need to bring along or have available to show for coping purposes. Monthly Payment Option If you are unable to pay your balance in full, please call Patient Accounts Department to set up an acceptable payment arrangement. Patient Charity/Financial Assistance Program If you feel your income is not sufficient to pay for your services at Columbus Community Hospital, please contact Patient Accounts Department AND/OR SOCIAL WORKERS for information regarding Charity/Financial Assistance. Further information about Medicare/Medicaid / Charity Care is provided in both English and Spanish. The state has their Medicaid applications available online. Our patient accounts and social services staff have financial/charity applications available in both English and Spanish to provide to our patients. Additionally, signage is posted directing patients to call as needed for financial help, and referrals are built into the Medical Admission software, so if patients voice concerns about the cost, or their lack of coverage a referral is generated to Social Services staff who will see patients individually and counsel on specific circumstances. Monthly statements have information on: 1)Payment plans 2)Charity/financial assistance program 3)24/7 online business office, which includes information on payment plans, charity/financial assistance, and downloadable financial/charity applications (available in English and Spanish).
COMMUNITY INFORMATION		The local economy- OUR HOSPITAL SERVICE AREA REMAINS IN A SMALL POCKET THAT HAS BEEN RELATIVELY PROTECTED FROM THE RECESSION. AS WE CURRENTLY HAVE OVER 300 SKILLED LEVEL POSITIONS AVAILABLE IN SEVERAL MANUFACTURING COMPANIES, INCLUDING PLASTICS, MEDICAL EQUIPMENT, ETHANOL AND THE LOCAL BEEF PACKING PLANT. COLUMBUS COMMUNITY HOSPITAL IS LOCATED IN COLUMBUS, NEBRASKA, WHICH IS THE LARGEST CITY IN PLATTE COUNTY. WITH A GROWING POPULATION OF 32,000, PLATTE COUNTY IS THE LARGEST OF THE SEVEN COUNTY SERVICE AREA. FROM JUNE 30, 2008 TO DECEMBER 31, 2009, UNEMPLOYMENT IN THE CITY OF COLUMBUS INCREASED SLIGHTLY FROM 3.0% OR 566 JOBLESS TO 3.7% OR 693 JOBLESS. DURING THIS SAME PERIOD OF TIME, THE NEBRASKA JOBLESS RATE WAS 4.6% AND THE NATIONAL AVERAGE WAS REPORTED AT 10%. SINCE NOVEMBER, 2008 JOB AVAILABILITY IN COLUMBUS HAS INCREASED BY 23%. THE UNEMPLOYMENT RATE REPORTED FOR COLUMBUS IN MAY, 2010 WAS 4.6%, WHILE THE STATE REPORTED 4.8% AND THE NATIONAL AVERAGE WAS 9.5%. AS REPORTED IN MONEY MAGAZINE, COLUMBUS IS LISTED AS THE THIRD BEST PLACE IN THE U.S. TO FIND EMPLOYMENT AND IN THE "TOP 100 BEST SMALL TOWNS TO LIVE". THREE COUNTIES IN NEBRASKA WERE LISTED IN THE TOP TEN COUNTIES IN THE U.S. TO LIVE AND WORK, INCLUDING PLATTE, MADISON (WHICH IS CONTIGUOUS TO PLATTE COUNTY) AND SARPY COUNTY NEAR LINCOLN, NEBRASKA. OUR LOCAL ECONOMY IS BASED ON AGRICULTURE AND MANUFACTURING, WITH MANY INDUSTRIAL COMPANIES ATTRACTED BY PLENTIFUL, LOW-PRICED HYDROELECTRIC POWER. AMONG THE MAJOR EMPLOYERS ARE ARCHER DANIELS MIDLAND (ADM), AN ETHANOL MANUFACTURING COMPANY; FLEX-CON; CENTRAL CONFINEMENT SERVICE; PILLEN FAMILY FARMS; VISHAY; BD MEDICAL PLANTS, A MEDICAL EQUIPMENT COMPANY; BEHLEN MANUFACTURING, WHICH MANUFACTURES STEEL BUILDINGS; AND NEBRASKA PUBLIC POWER, WITH HEADQUARTERS LOCATED IN COLUMBUS. DUE TO SUCCESSFUL ECONOMIC AND INDUSTRIAL DEVELOPMENT IN OUR AREA, THIS LARGE MANUFACTURING BASE REMAINS INTACT. A HARD-WORKING, WELL-EDUCATED WORKFORCE, LOW ENERGY COSTS AND A LOCAL ENVIRONMENT FRIENDLY TO BUSINESS, PROVIDE ENCOURAGEMENT FOR STRONG ECONOMIC AND INDUSTRIAL DEVELOPMENT WITHIN OUR SERVICE. ACCORDING TO THE NEBRASKA DEPARTMENT OF LABOR, COLUMBUS IS CONSIDERED A MAJOR HUB FOR THE MANUFACTURING INDUSTRY AND HAS A GREATER SHARE OF MANUFACTURING EMPLOYMENT THAN OTHER NEBRASKA METROPOLITAN AREAS. WE CONTINUE TO SEE AN INFLUX OF SINGLE AND YOUNG FAMILIES MOVING INTO OUR AREA SEEKING EMPLOYMENT. OUR COMMUNITY GROWTH CORRELATES TO OUR CONTINUING INCREASE IN HOSPITAL OUTPATIENT VISITS. OUTPATIENT VISITS REACHED 45,403 VISITS FOR THE FISCAL YEAR ENDING APRIL, 2013. THIS REPRESENTS A 0.6% INCREASE IN VISITS OVER THE SAME TWELVE MONTH PERIOD THE PRIOR YEAR. IN 2005, OUR OUTPATIENT VISITS OVER A TWELVE MONTH PERIOD TOTALED 38,129. THIS 19% INCREASE IN OUR OUTPATIENT VISITS OVER THE PAST SIX YEARS IS A REFLECTION OF THE SIGNIFICANT IMPACT THE DEMONSTRATION PROJECT HAS HAD ON OUR HOSPITAL. SERVICE CAPACITY: THE WOUND CENTER OPENED AUGUST OF 2008 WITH THREE PATIENTS. IT HAS GROWN TO 1,141 PATIENTS/VISITS AS OF APRIL 30, 2013. THE IDENTIFIED SERVICE AREA INCLUDES A 45-MILE RADIUS AROUND COLUMBUS. THE WOUND CENTER IS LOCATED IN THE VISITING PHYSICIAN OFFICE SUITE OF THE ATTACHED MEDICAL OFFICE BUILDING. THE CENTER OPERATES TWO DAYS PER WEEK. ADDITIONAL NURSE STAFF TIME IS SPENT EACH WEEK ASSISTING CLIENTS WITH WOUND APPLICATIONS, SCHEDULING APPOINTMENTS AND OTHER RESPONSIBILITIES SUCH AS ORDERING SUPPLIES AND MAINTAINING COMPLIANCE WITH NATIONAL STANDARDS. PREVIOUSLY, PATIENTS SEEKING THIS SPECIALIZED TREATMENT WERE REQUIRED TO TRAVEL ON AVERAGE 75 MILES TO SEE A WOUND CENTER SPECIALIST. THE VOLUME WE ARE SEEING AT THIS WOUND CENTER REINFORCES THE AMOUNT OF COMMUNITY NEED THAT EXIST FOR THIS SERVICE AND HAS GREATLY INCREASED THE LOCAL ACCESS TO SERVICE FOR SO MANY OF OUR HIGHER ACUITY PATIENTS AND THEIR FAMILIES. OUR NURSES ARE WCOM CERTIFIED, SO IN ADDITION TO WOUND CARE OUR PATIENTS WHO HAVE CHALLENGES WITH OSTOMY APPLIANCES AND SKIN CARE ARE TREATED. CCH INSTALLED A NEW CT SCANNER, NEW RADIOLOGIC/FLUSUSCOPY SYSTEM AND NUCLEAR MEDICINE CAMERA. THESE REPLACE EXISTING SYSTEMS WHICH ARE OUTDATED. WE RECENTLY OPENED A WOMEN'S IMAGING AREA WITHIN THE HOSPITAL WHICH IS SEPERATE FROM THE RADIOLOGY DEPARTMENT. A NEW REGISTRATION AREA RECENTLY OPENED WHICH PROVIDES PATIENT PRIVACY. WE REDUCED OUR MAMMOGRAPHY PROCEDURE PRICING 21% ON 2/8/12 AND SOUGHT AND RECEIVED A SUSAN G. KOMEN GRANT, WHICH THE HOSPITAL FOUNDATION MATCHED, TO PROMOTE MAMMOGRAPHY SCREENING FOR WOMEN IN THE COMMUNITY. BONE DENSITY, UPGRADED FROM CONTRACTING WITH A MOBILE SERVICE UNIT TO PURCHASING OUR OWN BONE DENSITY STATIONARY EQUIPMENT AND THE NECESSARY SUPPORT EQUIPMENT AND STAFF WHICH WAS ADDED IN EARLY 2010. THIS IS A GREAT ADDED BENEFIT TO THE COMMUNITY, INCREASING ACCESS FOR OUR PATIENTS AND PROVIDERS WHO NO LONGER HAVE TO AWAIT DIAGNOSIS WITH THE MOBILE UNITS' INTERMITTENT SERVICE. THIS IS ANOTHER NEW PROGRAM THAT INCREASES ACCESS AND ELIMINATES THE NEED TO TRAVEL TO OUT OF TOWN UNITS FOR PROMPT DIAGNOSIS THAT IS MADE POSSIBLE BY THE DEMONSTRATION PROJECT. THE DEMONSTRATION PROJECT HAS ALLOWED US TO PURCHASE ADDITIONAL EQUIPMENT, ELIMINATING THE WAIT FOR DIAGNOSIS DUE TO THE INTERMITTENT SERVICE OF MOBILE UNITS. THIS REDUCES THE NEED TO TRAVEL OUT OF TOWN FOR DIAGNOSIS AND IMPROVES ACCESS TO CARE FOR OUR COMMUNITY. COLUMBUS COMMUNITY HOSPITAL IS A 47 BED, ACUTE CARE HOSPITAL SERVING NEEDS OFFERING A VARIETY OF SURGICAL PROCEDURES AND SHORT TERM HOSPITALIZATIONS. ALL 47 BEDS ARE LICENSED FOR EITHER ACUTE CARE OR SWING BED PATIENTS. IN ADDITION, WE PROVIDE COMPREHENSIVE OUTPATIENT LABORATORY, RADIOLOGY, RESPIRATORY AND REHABILITATIVE SERVICES. WE ALSO PROVIDE FREE INTERPRETER SERVICES 24/7. OUR FACILITY OFFERS COMPREHENSIVE CARE, INCLUDING INTENSIVE CARE, MEDICAL-SURGICAL CARE, INPATIENT AND OUTPATIENT SURGICAL PROCEDURES (GENERAL, ENT, UROLOGY, PODIATRY, ORTHOPEDIC), AS WELL AS OTHER COMPLIMENTARY ANCILLARY SERVICES INCLUDING RESPIRATORY, WOUND CARE, DIABETES EDUCATION, ENDOSCOPIES AND CARDIOPULMONARY REHABILITATION. IN 2006, THE HOSPITAL'S EMERGENCY DEPARTMENT WAS DESIGNATED AS A LEVEL III TRAUMA CENTER WITH NURSES CERTIFIED IN TNCC, ACLS AND PALS. EIGHT OF THE EMERGENCY DEPARTMENT NURSES ARE ALSO CERTIFIED IN ENPC. A 30,000 SQUARE FOOT ADDITION TO THE HOSPITAL, PROVIDED THE EMERGENCY DEPARTMENT WITH EXPANDED SPACE. THE EMERGENCY DEPARTMENT ADDED TWO TRAUMA BAYS, A TWO-BAY AMBULANCE GARAGE, A DEDICATED DECONTAMINATION AREA, A DEDICATED FAMILY GRIEF AND COUNSELING ROOM, COVERED DRIVE-UP ACCESS AND A NEGATIVE AIR-PRESSURE ROOM, WHICH ALLOWS PATIENTS WITH COMMUNICABLE DISEASES TO BE TREATED WHILE PROTECTING OTHER PATIENTS AND STAFF. OUR HOME HEALTH/HOSPICE INTERDISCIPLINARY SERVICES ARE PROVIDED TO PATIENTS WITHIN A 30 MILE RADIUS OF COLUMBUS AND CAN PROVIDE IN HOME TELEHEALTH MONITORING. THE HOSPITAL'S SLEEP LAB PROVIDES POLYSOMNOGRAPHIC SLEEP TESTING. IN ADDITION, WE ARE EXPLORING THE POSSIBILITY OF MAKING AVAILABLE BOTH DAYTIME AND HOME SLEEP TESTS. IN JANUARY 2010, THE HOSPITAL HIRED A FULLTIME RN AS THE ORTHOPEDIC SERVICE LINE COORDINATOR. A MULTI-DISCIPLINARY TEAM WAS ORGANIZED TO REVIEW, STANDARDIZE AND IMPROVE THE PATIENT'S TOTAL JOINT PROCESS FROM DIAGNOSIS TO POST-SURGICAL RECOVERY AND IN NOVEMBER 2010 A NEW ORTHOPEDIC SERVICE LINE WAS IMPLEMENTED. IN MARCH, 2012 THE HOSPITAL ACQUIRED COLUMBUS ORTHOPEDIC AND SPORTS MEDICINE CLINIC, ENABLING THE HOSPITAL TO EXPAND THE SERVICE LINE AND ENSURE THE COMMUNITY'S AGING POPULATION ORTHOPEDIC SERVICES CLOSE TO HOME. THREE CARDIOLOGISTS HAVE RELOCATED TO COLUMBUS, PROVIDING FULL TIME CARDIOLOGY SERVICES TO THE AREA. SINCE 2010, 59 PHYSICIANS IN TOTAL HAVE BEEN RECRUITED TO SERVE THE NEEDS OF OUR PRIMARY AND SECONDARY SERVICE AREAS TO INCLUDE 54 MD'S AND 5 MIDLEVELS; 39 ARE FULL TIME PROVIDERS AND THE OTHER 28 ARE SERVING THE COMMUNITY IN A VISITING CAPACITY. THE HOSPITAL HAS COMPLETED CONSTRUCTION ON THREE ROAD PROJECTS ON AND AROUND THE CAMPUS TO INCREASE ACCESS TO THE FACILITY. TWO CLINIC BUILDINGS, ONE FOR A FAMILY PRACTICE GROUP AND ONE FOR A PHARMACY HAVE BEEN COMPLETED AS WELL.
PROMOTION OF COMMUNITY HEALTH		-The Hospital reinvests capital to improve patient care, attract the best qualified staff to provide quality care for our patients, provide medical education and prevention activities in the community. -Our Hospital is living our Mission and Vision within the community: OUR MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE OUR VISION IS TO COMPASSIONATELY DELIVER THE STATE'S HIGHEST QUALITY PATIENT CARE -CORE VALUES CCH Core Values are: INTEGRITY COMPASSION (changed from "Commitment" as part of the communication of this strategic plan) ACCOUNTABILITY RESPECT EXCELLENCE -The Hospital has prioritized our capital reinvestment by aligning it to the Strategic Plan. Our plan consists of SIX Organizational Pillars with goals and strategies associated with each. The SIX Pillars of Excellence consist of: Quality Culture People Services Facilities *FINANCE Measurement of ongoing operational performance is organized around these Pillars of Excellence. These pillars were strategically identified as common measures around which operational performance is organized in many health care institutions and adapted for CCH. COLUMBUS COMMUNITY HOSPITAL HAS AN INDEPENDENT BOARD OF DIRECTORS MADE UP OF COMMUNITY LEADERS WITH DIVERSE BACKGROUNDS. COLUMBUS COMMUNITY HOSPITAL HAS AN OPEN EMERGENCY ROOM AVAILABLE TO ALL IN NEED NO MATTER OF RACE, CREED, AGE, OR ABILITY TO PAY. THE HOSPITAL ALSO HAS AN OPEN MEDICAL STAFF.
AFFILIATED HEALTH CARE SYSTEM		N/A
STATE FILING OF COMMUNITY BENEFIT REPORT		NONE
PART V, LINE 14G		INFORMATION BROCHURES ON FINANCIAL/CHARITY ASSISTANCE (F/C) ARE AVAILABLE IN KEY AREAS OF THE HOSPITAL. THE CCH WEBSITE HAS INFORMATION REGARDING F/C ASSISTANCE, AS WELL AS APPLICATIONS IN BOTH SPANISH AND ENGLISH. THE PATIENT STATEMENTS HAS INFORMATION REGARDING F/C ASSISTANCE. THE F/C APPLICATIONS ARE AVAILABLE TO ALL STAFF ON THE H DRIVE UNDER FORMS. THE EMERGENCY REGISTRATION, MAIN REGISTRATION, PATIENT ACCOUNTS AND SOCIAL SERVICES DEPARTMENTS HAVE THE F/C APPLICATIONS IN BOTH ENGLISH AND SPANISH AVAILABLE.

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number
47-0542043

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) COLUMBUS COMMUNITY HOSPITAL FOUNDATION 4600 38TH STREET COLUMBUS,NE68601	47-0836747	501(C)(3)	60,383	TO SUPPORT EXEMPT
(2) American Heart Association Inc 7272 Greenville Ave Dallas,TX75231	13-5613797	501(c)(3)	5,398	To support exempt

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2012

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance
(1) CHARITY CARE TO PATIENTS	693	1,403,561	BOOK	WRITE-OFF OF MED EXP

Part IV

Supplemental Information.

Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Identifier	Return Reference	Explanation
GENERAL INFORMATION ON GRANTS AND ASSISTANCE	Schedule I, Part I, Line 2	COLUMBUS COMMUNITY HOSPITAL does not typically give out donations, but occasionally a request is brought forward and the Board determines that it is in the best interest of the community to provide a particular grant. Prior to providing the grant, the Hospital determines that the organization it gives to is a 501(c)(3) organization or a government agency. The Hospital will also make grants to their related organizations as necessary to support their exempt purpose.

Schedule I (Form 990) 2012

Additional Data

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- 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

2012

Open to Public Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

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 of the expenses described above? If "No," complete Part III to explain....

Yes

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? .......

Yes

Indicate which, if any, of the following the filing organization used 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? .........

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

Cat. No. 50053T

Schedule J (Form 990) 2012

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 (E) amounts for that individual.

(A) Name and Title		(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 and Title		(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)MARK HOWERTER MDDIRECTOR/PHYSICIAN	(i) (ii)	430,238 0	0 0	0 0	10,000 0	12,523 0	452,761 0	0 0
(2)MICHAEL HANSENPRESIDENT/CEO/SECRETARY	(i) (ii)	268,748 0	0 0	17,000 0	10,000 0	9,661 0	305,409 0	0 0
(3)J JOSEPH BARBAGLIAVP FINANCE	(i) (ii)	189,440 0	0 0	16,996 0	8,730 0	12,936 0	228,102 0	0 0
(4)LINDA WALLINEVP NURSING	(i) (ii)	161,727 0	0 0	16,250 0	6,651 0	12,476 0	197,104 0	0 0
(5)JAMES GOULETVP OPERATIONS	(i) (ii)	156,751 0	0 0	18,090 0	7,399 0	15,113 0	197,353 0	0 0
(6)ROBERT MILLER MDPHYSICIAN	(i) (ii)	232,484 0	0 0	0 0	9,374 0	10,226 0	252,084 0	0 0
(7)MICHAEL MCGUIRE MDPHYSICIAN	(i) (ii)	417,357 0	0 0	0 0	0 0	8,983 0	426,340 0	0 0
(8)RICHARD CIMPL MDPHYSICIAN	(i) (ii)	382,843 0	0 0	0 0	0 0	10,871 0	393,714 0	0 0
(9)EDWARD FEHRINGER MDPHYSICIAN	(i) (ii)	327,452 0	0 0	12,740 0	0 0	8,354 0	348,546 0	0 0
(10)ALEX KAZOS MDPHYSICIAN	(i) (ii)	229,409 0	0 0	0 0	5,130 0	8,926 0	243,465 0	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
QUESTIONS REGARDING COMPENSATION	PART I, LINE 1A	THE ORGANIZATION PAID FOR SOCIAL AND HEALTH CLUB DUES AS PART OF THE CEO'S EMPLOYMENT AGREEMENT. These amounts were reflected on the CEO's W-2.

Schedule J (Form 990) 2012

Additional Data

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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

2012

Open to Public
Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

Identifier	Return Reference	Explanation
GOVERNANCE, MANAGEMENT AND DISCLOSURE	FORM 990, PART VI, LINE 15	The Hospital's Executive Compensation Committee, made up of independent Hospital Board members, reviews the CEO's compensation annually. The wage range is compared to information provided by third party consultants, from salary surveys. Decisions are documented.
GOVERNANCE, MANAGEMENT AND DISCLOSURE	Form 990, Part VI, Line 19	At Columbus Community Hospital, a 3-ring binder exists in the Executive Assistant's office labeled "For Public Disclosure" which includes the most current of the following: -Governing Documents which are the Hospital Bylaws -Conflict of Interest Policy -Audited Financial Statements -Forms 990 and 990-T
GOVERNANCE, MANAGEMENT AND DISCLOSURE	Form 990, Part VI, Line 12C	Columbus Community Hospital does monitor any conflict of interests based on their conflict of interest policy. EMPLOYEES AND VOLUNTEERS are required to fully disclose any conflict of interest that may exist or appears to exist. Hospital reviews any of these conflicts and works with the Compliance Officer and the Vice President or CEO to determine if a conflict exists. If one does exist, the Hospital initiates actions to manage, reduce, or eliminate the conflict.
GOVERNANCE, MANAGEMENT AND DISCLOSURE	PART VI, LINE 11B	The Form 990 will be available for all members of the finance committee to review. Upon committee review, the 990 will then be submitted to the Board for review and the Board will make any corrections if applicable.
RECONCILIATION OF NET ASSETS	PART XI, LINE 9	CHANGE IN INTEREST IN HEALTHPARK LLC & ZARZ LLC (167,291)

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

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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

2012

Open to Public Inspection

Name of the organization

COLUMBUS COMMUNITY HOSPITAL INC

Employer identification number

47-0542043

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) 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" to 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 entity?
(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) COLUMBUS COMMUNITY HOSPITAL FOUNDATION 4600 38TH STREET COLUMBUS,NE68601 47-0836747	FUNDRAISING	NE	501(c)(3)	LINE 11, I	CCH	Yes
(2) HEALTHPARK TITLE CO 4600 38TH STREET COLUMBUS,NE68601 47-0830945	HOLDING CO.	NE	501(c)(3)	N/A	CCH	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) ZARZ LLC PO BOX 1800 COLUMBUS,NE68602 27-3676428	PROPERTY MGMT	NE	HLTHPK TITLE CO	related	0	0		No	0		No	50.000 %
(2) HEALTHPARK LLC PO BOX 1800 COLUMBUS,NE68602 47-0836733	PROPERTY MGMT	NE	HLTHPK TITLE CO	related	0	0		No	0		No	29.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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	(i) Section 512(b)(13) controlled entity?
(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	Yes	No

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

Yes

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

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

Yes

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) COLUMBUS COMMUNITY HOSPITAL FOUNDATION	b	60,383	Cash
(2) COLUMBUS COMMUNITY HOSPITAL FOUNDATION	c	117,549	cash
(3) COLUMBUS COMMUNITY HOSPITAL FOUNDATION	e	10,387,717	BOOK
(4) COLUMBUS COMMUNITY HOSPITAL FOUNDATION	m	155,955	book
(5) HEALTHPARK TITLE COMPANY	k	285,372	BOOK

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 2012

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
Part V, Line 2 (3)		COLUMBUS COMMUNITY HOSPITAL FOUNDATION IS LISTED AS BACKING THE COLUMBUS COMMUNITY HOSPITAL, INC.'S TAX EXEMPT BOND. THIS IS COVERED WITH THE FOUNDATION'S NON-ENDOWED FUNDS. The bonds were paid off In January, 2013.

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: OUR MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	11
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	10
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	649
6	Total number of volunteers (estimate if necessary) .............	6	333
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	17,330
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-39,795

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	303,177	117,549
9	Program service revenue (Part VIII, line 2g) .........	68,343,052	72,520,573
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,233,315	321,804
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	664,081	1,025,030
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	70,543,625	73,984,956
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	1,334,804	1,469,342
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)	30,379,279	33,905,776
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	27,885,114	29,781,927
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	59,599,197	65,157,045
19	Revenue less expenses. Subtract line 18 from line 12.......	10,944,428	8,827,911
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	100,607,338	97,892,656
21	Total liabilities (Part X, line 26).............	18,331,472	6,956,170
22	Net assets or fund balances. Subtract line 21 from line 20.....	82,275,866	90,936,486

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 61,819,521 including grants of $ 60,383 ) (Revenue $ 73,265,127 )
	General Hospital and Health Care: Columbus Community Hospital ("CCH") is a 47 bed acute care Hospital which currently employs over 600 people. It is a significant, positive economic force for Columbus and the area, returning dollars into the economy through local purchases by the organization, and salaries that return to the community. It is also a needed asset for the local communities where patients can obtain quality healthcare without the need to drive over 50 miles for care. In providing the care necessary for local communities, CCH has a variety of services. Following is a brief summary of some of the areas of service provided by CCH. -The main focus is acute care services For patients needing an extended recovery. the beds at CCH are also certified as swing beds. -To assist our non-English speaking patients, CCH uses competent, dedicated medical interpreters as a liaison between the care providers and the patient. Since this is the interpreters' full time job at the Hospital, they are available when needed, in house or on call 24/7. -To make the patient's stay successful and comfortable, CCH offers icu, medical surgical, OB, and an orthopedic service line along with a variety of complimentary ancillary services (wound care, diabetic education, cardiac rehab) and clinical pharmacy services provided. CCH uses barcoded medication administrated smart pumps and computerized physician order entry to enhance safety. -CCH offers rehabilitative services such as physical therapy, speech therapy, occupational therapy and drive rehab therapy, so patients don't have to travel so far to get adult therapy. Pediatric physical therapy, speech therapy, and occupational therapy are offered at our off-site location, Wiggles & Giggles Therapy (includes physicial, speech, and occupational therapies) for Kids. CCH has PTs, OTs and STs with specialized certification in cancer rehab. We launched our certified STAR Program at Columbus Community Hospital in November of 2012. We are one of only three hospitals in Nebraska to have achieved the STAR Program certification for cancer rehabilitation. STAR stands for Survivorship Training and Rehab. We have had at least 39 formal STAR Program referrals resulting in consultations for potential rehabilitation needs. Many of our STAR Program participants have needed physical therapy, speech therapy or occupational therapy and some have needed nutritional consults as well as psychosocial referrals. Some patients who have participated have had pulmonary concerns and cardiovascular factors. There also have been some STAR Program graduates that have transitioned to medical wellness here at CCH. STAR Program co-coordinators are Jill Jakub MOTR/L, CLT, and Michell Ruskamp MS, CCC-SLP. They are joined by 23 other clinicians including physicians, nurses, respiratory therapists, dieticians, social workers, and therapists who are STAR Program certified at CCH. The STAR Program Cancer Rehab Certification at CCH is funded by the Columbus Community Hospital Foundation. Our Certified Provider Team for the STAR Program is made up of 3 physicians, 6 physical therapists, 4 occupational therapists, 2 speech therapists, 4 nurses, 1 respiratory therapist, 3 social workers and 2 nutritionists. CCH HAS A specialized parkinsens treatment approach, which facilitates support groups for parkinsens, TBI and stroke patients. -Nurses in the Same Day Services Department prepare patients for surgery and if going home the same day, care for them after surgery. The department oversees several outpatient procedures, including seventy to ninety endoscopy procedures each month, also infusions and chemotherapy infusions. -CCH offers some of the most advanced imaging services including MRI, CT, Digital Mammography, Ultrasound, etc. Radiologists are on campus and/or available 24-7 to read the various scans. The dictation used by the radiologists is voice recognized and becomes part of the digital image. All images are digital, meaning there are no films. -CCH has an up to date Laboratory which performs over 12,000 tests on average per month, for both inpatients and outpatients. -CCH has highly trained, employed emergency physicians and nurses in their Emergency Department (ed) and offers 24-7 care. The Department includes support from qualified staff in respiratory care, social work, laboratory, medical interpreting, and diagnostic imaging. The ED was designated as a Level III Trauma Center in May, 2006. The Medical Staff and personnel in the Trauma Center have received specialized training to resuscitate and stabilize trauma patients. The trauma program provides systematic review of the trauma care and participates in injury prevention activities throughout the community. -CCH opened wound care services in August of 2008 with three patients. The identified service area includes a 45-mile radius around Columbus. By January, 2009 a second day was added to support the demand. This service has taken off far beyond what was expected. Previously, patients seeking this specialized treatment were required to travel on average 75 miles to see a wound clinic specialist. It was a much needed service for the local communities. Columbus commuinty hospital currently sees over 100 patients per month for wound care. -Centering on services outside the Hospital, the larger services are Home Health and Hospice services. Home Health is skilled health services for patients at their place of residence. The program is medically directed, therefore, it must be ordered by the attending physician. The program is Medicare and Medicaid certified and meets the requirements of the Joint Commission. Services provided within the program are: A) Supervision and administration of medications B) Intravenous therapy C) Teaching diabetic management D) Nutritional assessments E) Home Health Aides F) Personal Care services G) Occupational, Speech and Physical Therapies H) social work care management Hospice services are provided to persons who are no longer receiving curative treatment and whose life expectancy is six months or less. Care is provided by an interdisciplinary team which consists of the physician, nurse, social worker, therapist, home health aide, spiritual advisor, volunteer and other health professionals. -Our local Healthy Family Nebraska Program (HFN) targets young, primarily single, pregnant mothers and their families. Our voluntary HFN home visitation program targets the most vulnerable young women and their families by offering them, intense, in home education, support and resources. This home visiting program covers families in a four county area. The HFN requires each mother/family to actively participate in building an individualized family plan. This strength based approach promotes self-improvement, and enhances self-esteem and independence for our young parents that will help them make better decisions, and break out of destructive cycles. -CCH's Sleep Lab offers complete polysomnographic sleep testing for the purpose of diagnosing obstructive/central sleep apnea by trained and licensed sleep technicians. -Occupational Health Services (OHS) offers a menu of health care services designed to prevent and treat injuries in the workplace. Partnering with employers in more than 900 companies and with other health care professionals, OHS provides a comprehensive health and safety program specific to the needs of each business. A comprehensive testing procedure called the Physical Capacity Profile (pcp) matches employees to the job and is designed to accommodate individuals with handicaps. The PCP system was developed by an orthopedic physician. Through use of this testing, musculoskeletal imbalances are detected which helps employers place employees in the appropriate job to minimize the potential of injury. -Lifeline, an in home emergency response program, provides the vital safety net that many people need to continue living at home in familiar and comforting surroundings. The program is completely focused on ensuring the patient's independence, safety and well-being in their home. It operates with a bracelet worn by the patient with a button that can be pressed if help is needed. predetermined responders are summoned to their home or emergency transfer can be called if needed. This gives security to the patient and comfort to the patient's relatives. -Meals on Wheels are prepared by the Nutrition Services Department and are delivered by community volunteers. Seniors and physically handicapped adults qualify for the program. Special diets can also be accommodated. Financial assistance is available through the Nebraska Department of Social Services. -The Hospital participates in and has hosted county wide natural disasters and pandemic drills. CCH is a member of a larger preparedness team, RROMRS. This allows CCH to assist or receive assiStance from this regions medicare providers. CCH feels we are well prepared to handle a natural disaster or pandemic should one

4b	(Code: ) (Expenses $ 1,403,561 including grants of $ 1,403,561 ) (Revenue $ )
	Charity Care: CCH offers a Charity/Financial Aid Program to provide uncompensated services to people who are unable to pay. CCH Charity/Financial Aid Policy reflects the mission, vision and values of CCH. It is intended to assist low-income, underinsured, and uninsured individuals whose financial status, under the hospital's qualification criteria, makes it impractical or impossible to pay for necessary medical services. CCH has a fiduciary responsibility to seek payment for services from those who can pay, and every effort will be made to apply consistent, fair and equitable financial aid practices in a manner consistent with all applicable federal and state laws and regulations. CCH follows the Federal Poverty Guidelines (FPG) to determine both eligibility for free care, 100% of FPG, and discounted care, 200% FPG. CCH also offers catastrophic charity assistance. If the applicant qualifies for partial Charity/Financial Assistance and the total balance after all write-off's is $1,200 or greater, an additional write-off will be done as outlined below. Reduce to $1,200, adjustments will be done from oldest to newest.

4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses63,223,082

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	2,995,278	0	141,912

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(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) MICHAEL MCGUIRE MD........................................................................ PHYSICIAN	40.0 .......................0.0	X	417,357	0	4,997
(19) RICHARD CIMPL MD........................................................................ PHYSICIAN	40.0 .......................0.0	X	382,843	0	6,885
(20) EDWARD FEHRINGER MD........................................................................ PHYSICIAN	40.0 .......................0.0	X	340,192	0	5,108
(21) ALEX KAZOS MD........................................................................ PHYSICIAN	40.0 .......................0.0	X	229,409	0	10,082

				(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		117,549
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			117,549
			Business Code
2a	NET PATIENT SVC REVENUE		621110	72,313,254	72,313,254
b	MEANINGFUL USE PAYMENT		900099	207,319	207,319
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			72,520,573
3	Investment income (including dividends, interest, and other similar amounts).......			318,431			318,431
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)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		3,373
b	Less: cost or other basis and sales expenses
c	Gain or (loss)		3,373
d	Net gain or (loss)..........			3,373			3,373
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	MEALS ON WHEELS		900099	50,021	50,021
b	CAFETERIA		722100	263,146			263,146
c	OTHER REVENUE		900099	711,863	694,533	17,330
d	All other revenue ....
e	Total. Add lines 11a–11d ......			1,025,030
12	Total revenue. See Instructions......			73,984,956	73,265,127	17,330	584,950


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			5,507,494	1	1,933,467
2	Savings and temporary cash investments .........			0	2	0
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			8,997,202	4	9,233,671
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			1,454,475	8	1,077,673
9	Prepaid expenses and deferred charges ..........			1,418,337	9	1,512,950
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	86,726,440
b	Less: accumulated depreciation .....	10b	49,024,725	37,861,816	10c	37,701,715
11	Investments—publicly traded securities ..........			45,055,102	11	46,218,318
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
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 ...........			312,912	15	214,862
16	Total assets. Add lines 1 through 15 (must equal line 34)......			100,607,338	16	97,892,656
17	Accounts payable and accrued expenses .........			6,699,617	17	6,956,170
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			11,631,855	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other 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 ..			0	23	0
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....................			0	25	0
26	Total liabilities. Add lines 17 through 25.........			18,331,472	26	6,956,170
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			82,275,866	27	90,936,486
28	Temporarily restricted net assets ...........			0	28	0
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........			82,275,866	33	90,936,486
34	Total liabilities and net assets/fund balances ........			100,607,338	34	97,892,656