TY 2015 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) Brian Schmidt...................................................................... Chairman	1.0 ................. 0.0	X	X	0	0
(2) Clark Lehr...................................................................... Vice Chairman	1.0 ................. 0.0	X	X	0	0
(3) Brett Bonwell...................................................................... Treasurer	1.0 ................. 0.0	X	X	0	0
(4) Beth Przymus...................................................................... Director	1.0 ................. 0.0	X		0	0
(5) Bonnie McPhillips...................................................................... Director	1.0 ................. 0.0	X		0	0
(6) Christian VanKirk MD...................................................................... Director	1.0 ................. 0.0	X		0	0
(7) Jeffrey Gotschall MD...................................................................... Director	1.0 ................. 0.0	X		0	0
(8) Ronald Ernst MD...................................................................... Director	1.0 ................. 0.0	X		0	0
(9) Stan Emerson...................................................................... Director	1.0 ................. 0.0	X		0	0
(10) Tim Tooley...................................................................... Director	1.0 ................. 0.0	X		0	0
(11) Amy Blaser...................................................................... VP Business Development	40.0 ................. 0.0		X	191,220	37,752
(12) Chad Van Cleave...................................................................... VP Finance	40.0 ................. 0.0		X	119,261	36,900
(13) J Joseph Barbaglia...................................................................... VP Finance - Retired	40.0 ................. 0.0		X	170,375	19,488
(14) Scott Messersmith...................................................................... VP Operations	40.0 ................. 0.0		X	109,343	26,336
(15) James Goulet...................................................................... VP Operations - Retired	40.0 ................. 0.0		X	213,515	32,333
(16) Linda Walline...................................................................... VP Nursing	40.0 ................. 0.0		X	196,070	29,592
(17) Michael Hansen...................................................................... President/CEO/Secretary	39.0 ................. 1.0		X	405,910	70,122

(A) Name and business address	(B) Description of services	(C) Compensation
TSP Construction Services Inc, 1112 N West Ave Sioux Falls,SD571041333	Construction	4,833,755
McKesson Technologies Inc, PO Box 98347 Chicago,IL60693	IT Consulting	924,697
Inpatient Physician Associates, 3200 Pine Lake Rd Suite A Lincoln,NE68516	Hospitalist Svcs	694,106
Renovo Solutions LLC, 1801 E Park Court Plaza Suite 206 Santa Ana,CA92701	Equipment Maint	167,281
The Roberts Group Inc, 730 N Grand Ave Waukesha,WI53186	Marketing Company	101,852
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 5

- 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.
right arrow

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

Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 (Form 990 or 990-EZ))

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 in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

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

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.)..
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 section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. 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—2014. 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—2015. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. 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 VI 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) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.) ..
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 section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. 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—2014. 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) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2015 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

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.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled 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 totaling $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 its Form 990PF, Part I, line 2, 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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization Columbus Community Hospital Inc		Employer identification number 47-0542043

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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization Columbus Community Hospital Inc			Employer identification number 47-0542043
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ 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) (2015)

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

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), 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-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(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) 2015

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 on 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

6,547

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

6,547

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

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, Part II-B, Line 1i	Dues paid to American Hospital Association allocated to lobbying $3,052 and dues paid to Nebraska Hospital Association allocated to lobbying $3,495.

Schedule C (Form 990 or 990EZ) 2015

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," on 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.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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" on Form 990, Part IV, line 6.

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of 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" on 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on 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)

Revenue included on 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:

Revenue included on 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) 2015

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
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, for escrow or custodial account liability?

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" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....	1,806,283	1,798,246	1,742,125	1,667,736	1,573,063
b	Contributions ...	25,774	8,037	56,121	74,389	94,673
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......	1,832,057	1,806,283	1,798,246	1,742,125	1,667,736

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

100.000 %

Temporarily restricted endowment SchDMd Bullet

The percentages on 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" on 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.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land ...	1,152,275		1,152,275
b	Buildings	63,099,138	24,253,050	38,846,088
c	Leasehold improvements
d	Equipment ...	44,522,290	36,977,299	7,544,991
e	Other ...	7,117,751	2,437,827	4,679,924
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				52,223,278

Schedule D (Form 990) 2015

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11b. 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
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	0
2. Liability for uncertain tax positions. 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) 2015

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) 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. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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

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.

Return Reference

Explanation

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, Part X, Line 2

The Hospital adopted Financial Accounting Standards Baord (FASB) Interpretation No. 48, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No, 109. 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 2016 and 2015, management determined that there are no income tax positions requiring recognition in the financial statements.

Schedule D (Form 990) 2015

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" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 criteria used 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? . . . . . .

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) . . .		511,365	0	511,365	0.720 %
b	Medicaid (from Worksheet 3, column a) . . . . .		4,144,286	958,970	3,185,316	4.470 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .		0	0	0
d	Total Financial Assistance and Means-Tested Government Programs . . . . .		4,655,651	958,970	3,696,681	5.190 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	64,175	266,012	4,872	261,140	0.370 %
f	Health professions education (from Worksheet 5) . . .		779,233	7,992	771,241	1.080 %
g	Subsidized health services (from Worksheet 6) . . . .		0	0	0
h	Research (from Worksheet 7) .		0	0	0
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .		36,437	0	36,437	0.050 %
j	Total. Other Benefits . .	64,175	1,081,682	12,864	1,068,818	1.500 %
k	Total. Add lines 7d and 7j .	64,175	5,737,333	971,834	4,765,499	6.690 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

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.

		(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		415,654	44,422	371,232	0.520 %
2	Economic development	690	5,000		5,000	0.010 %
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	347	14,759	24,502
7	Community health improvement advocacy
8	Workforce development	205	426		426
9	Other
10	Total	1,242	435,839	68,924	376,658	0.530 %

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. ......

5,429,402

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).....

21,337,861

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

25,697,467

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

-4,359,606

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	(c) Organization's profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1HealthPark LLC	Property management	27.21 %	72.79 %
2ZARZ LLC	Property management	44.45 %	55.55 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2015

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, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)					Other (Describe)
1	Columbus Community Hospital Inc 4600 38th Street Columbus,NE686011800 www.colubushosp.org License #630001	X	X	X	47 Bed Acute Care Hospital w/ 24 hr ER Services

Schedule H (Form 990) 2015

Page 4

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 letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

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 significant 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 Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 14

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

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 (list url): See Section C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 14

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): See Section C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Columbus Community Hospital Inc
Name of hospital facility or letter of facility reporting group

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 100% and FPG family income limit for eligibility for discounted care of 200.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

See Section C

The FAP application form was widely available on a website (list url):

See Section C

A plain language summary of the FAP was widely available on a website (list url):

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

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 all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

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 individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	Columbus Community Hospital Inc
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (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 individuals regarding the individuals’ bills

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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 Section C)

Other (describe in Section C)

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 Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual 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 Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Schedule H, Part V, Line 5	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 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 HOSPITAL'S PARTICIPATION IN THE CURRENT MAPP ASSESSMENT IS THE MOST THOROUGH TO DATE WITH OVER 100 INDIVIDUALS IN THE DISTRICT PARTICIPATING IN THE PROCESS. THIS DOES NOT COUNT THE 1,000 INDIVIDUAL SURVEYS OR FOCUS GROUP PARTICIPANTS.
Schedule H, Part V, Line 6a	- Alegent Health Memorial Hospital, Schuyler - Genoa Community Hospital - Boone County Health Center
Schedule H, Part V, Line 6b	- Columbus Area United Way - East Central District Health Department
Schedule H, Part V, Line 7a	The detailed assessment and related components are available via link on https://www.columbushosp.org/news_events/community_health_needs_assessment _chna.aspx or available on request and available for review at Columbus Community Hospital.
Schedule H, Part V, Line 10a	THE IMPLEMENTATION STRATEGY IS AVAILABLE VIA LINK ON HTTPS://WWW.COLUMBUSHOSP.ORG/NEWS_EVENTS/CHIP_IMPLEMENTATION_PLAN.ASPX
Schedule H, Part V, Line 11	CHNA Identified Health Care Needs The following "health priorities" were identified as recommended areas of intervention under the CHNA conducted in collaboration with the East Central District Health Department (contracting with Schmeekle Research, Inc.), covering the counties of Platte (where CCH is located), Boone, Colfax and Nance: - Access to health care - Obesity - Family support - Substance abuse - Mental health CCH will work hand-in-hand with the East Central District Health Department and other health and business-related agencies to address these needs. Specifically, CCH will take the lead in addressing the identified needs of access to health care and obesity by conducting the activities described below. It will support the identified needs of family support, substance abuse and mental health as requested by other participants of the CHNA that have agreed to take the lead in these areas. These participants already have programs in place and expertise in these areas. The allocation of duties in addressing these identified health care needs promotes program effectiveness and supports the efficient allocation of limited health care dollars. Implementation Strategy Access to health care: Improve access to comprehensive, quality health care services. CCH will take the lead exploring and/or implementing the following: - Objective: Reduce the death rate from cancer of the uterus/cervix. - Action Step: Explore ways to provide a free PAP screening event at CCH. Collaborate with the University of Nebraska Medical Center on cancer management. - Objective: Reduce the female breast cancer death rate. - Action Step: Research funding options to increase the number of uninsured/underinsured women's access to mammography. An application was submitted on December 13, 2012 to the Susan G. Komen Foundation for a grant in the amount of $9,000. - Objective: Reduce one of the barriers to care. Look at the feasibility of creating a volunteer transportation program for patients. - Action Step: Explore programs operated by volunteers. - Objective: Explore other disease health screening opportunities to increase access to health care and develop a plan to address early screening. - Action Step: CCH will take the lead for the Tune Up For Life Health Fair and explore options for more screenings. - Objective: To increase access to care, facilitate communication opportunities between providers and patients. - Action Step: Provide and support nurse triage line to area local providers for a small fee. - Objective: Implement a home monitoring program for patients receiving home health services. - Action Step: Ensure home health tele-monitoring systems are being utilized by patients. - Objective: Provide community screenings and an information day regarding diabetes. - Action Step: CCH will be the lead for Diabetes Awareness Day, scheduled year in October. - Objective: Explore forming a geriatric assessment team to complete patient testing and evaluation of best setting for patients. - Action Step: Collaboration with Pender Hospital and Columbus Family Practice. Family Support: To improve the stability, health and well-being of women, infants, children and families through the effective use of community resources. The child well-being work group will take the lead in exploring and/or implementing the objectives and action steps. Obesity: Promote healthy weight and reduce chronic disease risk. Columbus Community Hospital's dedication to helping create a healthier community is seen in the Hospital's commitment to building the Columbus Wellness Center. The Center not only provides increased access to exercise and fitness, but to registered dietitians as well. Through classes and individual consultation, the dietitians can help address lifestyle changes that decrease health issues associated with obesity and chronic disease. CCH is also taking the lead in exploring and/or implementing the following: - Objective: Reduce the number of adults who are considered obese. - Action Step: Include the Chamber of Commerce and meet with local HR representatives monthly to develop a worksite wellness plan that is user-friendly and can be packaged and ready for business use. - Objective: Grow the Platte County CHIP Obesity Prevention Coalition and gather resources for public distribution. - Action Step: Have coalition members invite other community agencies and individuals to join. Gather list of resources available for physical activity and nutrition and distribute to area businesses. Regularly publish articles in newspaper and on the website. Substance Abuse: Reduce substance abuse to protect the health, safety and quality of life for all, especially children in grades 6-12. The East Central District Health Department, Columbus Police Department and Platte County Sheriff's Department will take the lead in exploring and/or implementing the objectives and actions steps. CCH will provide advice and support as requested. Mental Health: Improve mental health through prevention and by ensuring access to appropriate, quality mental health services. The Platte County Mental Health CHIP group will take the lead in exploring and/or implementing the objectives and action steps. CCH will provide advice and support as requested.
Schedule H, Part V, Line 16a	https://www.columbushosp.org/for_patients_visitors/patients_financial_info rmation/discount_charity_care_programs.aspx
Schedule H, Part V, Line 16b	https://www.columbushosp.org/sites/www/Uploads/Charity-Financial%20Assista nce%20Application%20-%20English.pdf https://www.columbushosp.org/sites/www/Uploads/Charity-Financial%20Assista nce%20Applicaiton%20-%20Spanish.pdf
Schedule H, Part V, Line 16i	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 and the patient statements also contain information regarding F/C assistance. The F/C applications are available to all staff on the Hospital's internal "h" drive under the "forms" category. The Hospital's Emergency Department registration desk, main registration area, patient accounts desk and Social Services Department all have F/C applications readily available in both English and Spanish.

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

Section D. 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?10
Name and address		Type of Facility (describe)
1	Premier Physical Therapy of CCH US 30 Center Bldg 3100-23rd St St Columbus,NE686013161	Outpatient Physical Therapy SPORTS TRAINING SERVICES
2	Wiggles & Giggles Therapy for Kids 3912 38th Street Suite B 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 St Suite 165 Columbus,NE68601	Wound Treatment Center
5	Humphrey Clinic of CCH 3003 Main Street Humphrey,NE686423155	Clinic in small town to offer medical services to residents
6	Hospice of Columbus Community Hospital 3005-19th St Suite 600 Columbus,NE686014248	Hospice Services
7	Columbus Community Hospital Sleep Lab 3020-19th St Suite 100 Columbus,NE686014252	Polysomnographic Sleep Testing
8	Home Health of Columbus Community Hosp 3005-16th St Suite 600 Columbus,NE686014248	Home Health Services
9	Columbus Orthopedic & Sports Med Clinic 4508 38th St Suite 133 Columbus,NE686011668	Free Standing Clinic
10	Rehabilitative Services 3912 38th Street Suite B Columbus,NE686015100	Outpatient Physical Therapy, Occupational Therapy and Speech Therapy

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
Schedule H, Part I, Line 3c	N/A
Schedule H, 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.
Schedule H, Part I, Line 7b	THE REVENUE GENERATED BY MEDICAID PATIENTS IS MULTIPLIED BY THE COST TO CHARGE RATIO DEVELOPED IN WORKSHEET 2. THE REMAINING PRODUCT IS THE CALCULATED COST ASSOCIATED WITH THE CHARGES FROM MEDICAID PATIENTS. THESE COSTS ARE REDUCED BY THE REIMBURSEMENTS COLLECTED FOR THE MEDICAID CHARGES. THE REMAINING NUMBER IS THE NET COMMUNITY BENEFIT EXPENSE. Schedule H, PART I, LINE 7E EXPENSES REPRESENT WAGES ALONG WITH SERVICES AND SUPPLIES PURCHASED BY THE HOSPITAL. DIRECT OFFSETTING REVENUES REPRESENT CASH COLLECTED FOR THESE SERVICES. Schedule H, PART I, LINE 7I CASH DONATIONS REPRESENT THE MAJORITY OF THESE DONATIONS, THE LARGEST AMOUNT, $25,000, GOING TO THE EAST CENTRAL DISTRICT HEALTH DEPARTMENT TO SUPPORT COMMUNITY HEALTH PROGRAMS. OTHER CASH DONATIONS WERE MADE TO SMALLER ORGANIZATIONS FOR PROGRAMS OR EVENTS RELATING TO HEALTH. THE IN-KIND DONATIONS, $101, WERE MEALS ON WHEELS CARDS FOR THOSE WHO COULD NOT AFFORD THE MEALS. Schedule H, PART I, LINE 7, COLUMN (F) THE AMOUNT OF 71,248,689 USED AS THE DENOMINATOR TO COMPUTE COLUMN (F) IS CALCULATED BY TAKING TOTAL FUNCTIONAL EXPENSES OF 76,678,091 MINUS BAD DEBT EXPENSE OF 5,429,402.
Schedule H, Part II	Community Building Activities Columbus Community Hospital (CCH) continues to collaborate with the local Chamber of Commerce to recruit skilled professionals to fill job openings in the community. The Hospital also provides support and staff time to assist in highlighting the health care community, offering specific department or Hospital tours in order to recruit skilled professionals to live and work in Columbus. On Hospital-donated land, the City of Columbus created a twelve acre urban lake and, on the same property, an additional 20 acres designated as the future site of a fire station. A handicap/stroller-accessible dock on the urban lake allows access for fishing or to watch water fowl rest in the area as they migrate through Columbus. The urban lake provides a community space within the city limits for people of all ages. The Hospital continues to partner with our local public health department and community health center (CHC) on several projects and community disease prevention initiatives, providing financial support and professional staff time as liaisons to these community partnerships throughout the year. Working together with these agencies, some of the chronic disease and accident prevention strategies addressed include: Type II Diabetes, hypertension and heart disease, pre and postnatal newborn care, physical activity and exercise, colon cancer prevention and early detection, and community preparedness for natural and man-made disasters. These programs reach countless members of the community each year, making a difference in the lives of people living with chronic health issues. Other hospital-driven community health initiatives include: free flu shots for residents at the shelter for the homeless and participation in numerous community health fairs/events each year providing medical screenings and free health information/education. To encourage entry into the medical profession, Columbus Community Hospital partners with local day care facilities, area schools and colleges, offering its medical professionals as guest speakers or instructors at hands-on learning events. To help in recruitment of health care professionals and also to relieve the daycare shortage in Columbus, the Hospital Board has also approved the construction of an on-site daycare and pre-school for Hospital employees. Columbus Community Hospital has an independent Board of Directors, consisting of community leaders with diverse backgrounds. The CCH Board approved the construction of a $21 million, 85,723 square foot community wellness facility that opened on October 27, 2015. The Columbus Family YMCA leased, below fair market value, 62,397 square feet of the facility that is available for use by the entire community and includes: 2 gyms, 3 pools, and weight and exercise equipment. Classes for wellness and fitness are provided by health care professionals from the Hospital and YMCA staff. In separate areas, the facility also houses the Hospital's adult and pediatric therapies.
Schedule H, Part III, Line 2	The methodology used to estimate bad debt expense is to take the private pay write-offs for the year and divide them by the total revenue generated from self-pay patients and multiply the product by the self-pay accounts receivable. This gives the amount of reserve necessary to cover the potential bad debt in current self-pay accounts receivable. Bad debt expense for the fiscal year is the amount of additional expense necessary to bring that reserve account to the calculated (estimated) balance.
Schedule H, Part III, Line 3	N/A
Schedule H, 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.
Schedule H, 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., routing 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. 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 service 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 non-revenue-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.
Schedule H, Part III, Line 9b	The purpose of our Financial Assistance/Charity Program is to further the charitable mission of CCH by providing financially disadvantaged and other qualified patients with an avenue to apply for and receive free or discounted care consistent with the requirements of the Internal Revenue Code and implementing regulations under IRC Section 501(r). CCH's Financial Assistance Policy reflects the mission, vision and values of CCH. It is intended to assist low income, uninsured and underinsured individuals whose financial status, under the hospital's qualification criteria, makes it impractical or impossible to pay for medically necessary and emergency care. This Program provides a fair and comprehensive system of distributing free or discounted medical care to poor and financially disadvantaged patients within the available resources of CCH. This Policy addresses; Eligibility criteria for financial assistance; The extent to which financial assistance includes free and discounted care; The basis for calculating amounts charged to eligible patients; The method for applying for assistance; Actions that may be taken by CCH in the event of nonpayment; and Measures to widely publicize the Policy. CCH recognizes the individual's right to obtain quality health care regardless of age, sex, race, disability, national origin, marital status, sexual orientation, personal beliefs or their ability to pay. CCH has a fiduciary responsibility to seek payment for services from those who can pay.
Needs Assessment	In 2010, Columbus Community Hospital began implementing a five year strategic plan. The plan includes a thorough assessment of the organizations external environment in terms of opportunities and threats, as well as an assessment of the organizations 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 (EBP) and educating staff on the importance of using and integrating these processes in daily operations. CCH has implemented an electronic medical record to afford ease of information access and communication across the continuum of care. The clinical leadership groups for nursing and respiratory therapy have initiated a review of how to integrate EBP into the clinical areas and will be starting classes to educate staff within and outside nursing. 2) Culture: In an effort to achieve a high performance organization, CCH is in the process of implementing a 4-part culture improvement initiative that includes: TeamSTEPPS, Just Culture, Student and Lean/Six Sigma Process Improvement. The Hospital continues to work with the Studer Group to hardwire appropriate tools, focusing on improving patient outcomes and create a culture/environment, making CCH and employer of choice, and where physicians want to bring their patients for care. 3) People: CCH has continued to be aggressive in its recruitment efforts to attract and retain the workforce needed to support strategic growth initiatives across all service lines. CCH is initiating a new on-boarding process for new employees. In addition, nursing has updated their orientation program and has trained preceptors and nurse mentors/coaches. 4) Services: CCH performs an annual comprehensive program review of existing and new services and has ranked priority service line development in the areas of hospital medicine, orthopedics, cardiology, cancer and rehab services. 5) Facilities: CCH has developed a comprehensive master facilities plan that can adapt to current and future patient care needs. An Emergency Department expansion was completed in 2012 with a new Medical Office Building recently completed to house visiting physicians and the Wound, Ostomy, and Continence Care (W.O.C.) Clinic. 6) Finance: CCH is working diligently to maintain financial stability. Our approach includes: work to extend the Demonstration Project with an alternate plan in place if the program is discontinued. The Hospital maintains a conservative successful investment strategy and continue growth in the CCH Foundation.
Patient Education of Eligibility for Assistance	Financial assistance information is available on the Hospitals website, including links to additional, in-depth information. Patient Charity/Financial Assistance Program: 1) If patients feel their income is not sufficient to pay for services at Columbus Community Hospital, they are encouraged to contact the Patient Accounts Department and/or Social Workers for information regarding charity/financial assistance. 2) Further information about Medicare/Medicaid/Charity Care is provided in both English and Spanish on our website. The State has Medicaid applications available online. Our Patient Accounts and Social Services staff can provide patients with financial/charity applications in either English or Spanish. 3) Additionally, signage is posted directing patients to call as needed for financial help. Referrals are built into to the medical admission software. If patients share 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. 4) Monthly statements include the following information: a. Payment plans b. Charity/Financial Assistance Program c. 24/7 online Business Office access, which includes information on payment plans, charity/financial assistance and applications for financial/charity assistant available in both English and Spanish that can be downloaded from our website. A hard copy with information is also available in the Guide to Patient Services located in each patients room, as well as informative brochures located in outpatient areas. A step-by-step tutorial is also available, to help educate patients regarding what they need to bring when registering.
Community Information	The Local Economy Columbus Community Hospital is located in Columbus, Nebraska, which is the largest city in Platte County. With a growing population of 33,066, Platte County is the largest county of the seven counties in the CCH service area. From July, 31, 2013 to July 31, 2014, unemployment in the City of Columbus decreased slightly from 3.9% or 756 jobless to 3.3% or 610 jobless. During this same period of time, the Nebraska jobless rate was 3.6% and the National average was reported at 6.2%. 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. 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 area. Among the major employers are Archer Daniels Midland (ADM), an ethanol manufacturing company; FLEXCON; Central Confinement Services; Pillen Family Farms; Vishay; two BD Medical Plants, medical equipment companies; Behlen Manufacturing, which manufactures steel buildings; and Nebraska Public Power, with headquarters located in Columbus. 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 44,613 visits for the fiscal year ending April, 2014. In 2005, our outpatient visits over a twelve month period totaled 38,129. This 17% increase in our outpatient visits over the past nine years is a reflection of the significant impact the Demonstration Project has had on our Hospital. Service Capacity The W.O.C. Clinic opened in August of 2008. It has grown to 1,107 patients/visits as of April 30, 2014. The identified service area includes a 45-mile radius around Columbus. The W.O.C. Clinic is located in the visiting physician office suite in the attached Medical Office Building. The Clinic has scheduled visits two days per week with additional nurse staff time spent each week assisting outpatient clients with wound applications, as well as assisting in the application of wound vacs in surgery or on our medical floor. W.O.C. staff also schedules appointments and other responsibilities for the Clinic such as ordering supplies and maintaining compliance with national standards. Prior to the opening of the W.O.C. Clinic, patients seeking this specialized treatment were required to travel an average of 75 miles to see a wound center specialist. The volume we are seeing at this Clinic reinforces the amount of community need that existed for this service and has greatly increased local access for so many high acuity patients and their families. Our nurses are WCOM certified, so in addition to wound care, patients who have challenges with ostomy appliances and continence problems can be addressed through our Clinic. To replace older, existing systems, CCH recently installed a new CT scanner, new radiologic/fluoroscopy system and nuclear medicine camera. The Hospital recently opened a womens imaging area within the Hospital, which is separate from the rest of the Radiology Department. The registration area was recently renovated which provides additional privacy for patients. On February 8, 2012, we reduced our mammography procedure pricing by 21% as well as sought and received a Susan G. Komen grant. The grant provided uninsured and underinsured women in our community access to lifesaving mammograms. The Hospitals Foundation also provided matching funding for the grant. Because of the Hospitals participation in the Demonstration Project, CCH was able to purchase bone density equipment, support equipment and train staff in the use of this procedure. In the past, CCH had contracted for mobile density services, but the purchase of this equipment has increased access to care for our community and eliminated the need to wait for diagnosis from a mobile units intermittent service or travel out of town for the procedure. Columbus Community Hospital is a 47 bed, acute care hospital 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, CCH provides comprehensive outpatient laboratory, radiology, respiratory and rehabilitative services. We also provide free 24/7 interpreter services. Our facility offers comprehensive care, including intensive care, medical-surgical care, inpatient and outpatient general, ENT, urology, podiatry, orthopedic surgical procedures. Other ancillary services offered include: respiratory, wound care, diabetes education, endoscopy and cardiopulmonary rehabilitation. In 2006, the Hospitals 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 ED was completed in 2012. The expanded area allowed the ED to add 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 disease to be treated while protecting other patients and staff. CCH has an open emergency room available to all in need regardless of race, creed, age or ability to pay. The Hospital also has an open medical staff. The Hospitals Home Health/Hospice interdisciplinary services are available to patients within a 30 mile radius of Columbus, offering in-home telehealth monitoring. The CCH Sleep Lab provides polysomnographic sleep testing, available for both daytime and home sleep tests. In January 2010, the Hospital hired a fulltime RN as the Orthopedic Service Line Coordinator. In November of that same year, a multi-disciplinary team was organized to review, standardize and improve the patients total joint process from diagnosis to post-surgical recovery. In March 2012, the acquired Columbus Orthopedic and Sports Medicine Clinic, enabling the Hospital to expand the service line and ensure the communitys aging population orthopedic services close to home. In May, 2013, the Hospital expanded the RN Coordinators responsibility into case management in the Transitional Care Department. This expansion of duties enabled the Hospital to plan for continuity of care post-hospitalization. Three cardiologists have relocated to Columbus, providing full time cardiology services to the area. Since 2010, 63 physicians have been recruited to serve the needs of our primary and secondary service areas, including 55 MDs, 1 DPM and 7 mid-level providers. Thirty-four of these providers are full time, while the other 29 are serving in a visiting capacity. To increase access to CCH, the Hospital has completed construction on three road projects on and around the campus. Two clinic buildings, one for a family practice group and one for a pharmacy, have been completed as well.
Promotion of Community Health	In addition to construction of the Columbus Wellness Center, the Hospital reinvests capital to improve patient care, attract the best qualified staff, and provide medical education and prevention activities in our community. The Hospital is living its mission and vision within the community. Our Mission: To improve the health of the communities we serve. Our Vision: To compassionately deliver the States highest quality of patient care. Columbus Community Hospitals care values are: - Integrity - Compassion - 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 to each. The six Pillars of Excellence are: - Quality - Culture - People - Services - Facilities - Finance Measurement of ongoing operational performance is organized around these pillars. The pillars were strategically identified as common measures around which operational performance is organized in many health care institutions and adapted for CCH.
Affiliated Health Care System	N/A
State Filing of Community Benefit Report	None

Schedule H (Form 990) 2015

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," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on 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 section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)

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) 2015

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on 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	(c) Amount of cash grant	(d) Amount of non-cash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of non-cash assistance

(1) CHARITY CARE TO PATIENTS	838	1,135,610	BOOK	WRITE-OFF OF MED EXP
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Return Reference

Explanation

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 these related organizations as necessary to support their exempt purpose.

Schedule I (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 on 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
directors, trustees, officers, including 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 on Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

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

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

Yes

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

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization?

Yes

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

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

For persons listed on 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 on 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" on 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) 2015

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 on 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 in column(B) reported as deferred on 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)
1Amy BlaserVP Business Development	(i) (ii)	129,347 ------------- 0	11,800 ------------- 0	50,073 ------------- 0	15,730 ------------- 0	23,844 ------------- 0	230,794 ------------- 0	0 ------------- 0
2Chad Van CleaveVP Finance	(i) (ii)	119,261 ------------- 0	0 ------------- 0	0 ------------- 0	14,878 ------------- 0	23,519 ------------- 0	157,658 ------------- 0	0 ------------- 0
3J Joseph BarbagliaVP Finance - Retired	(i) (ii)	75,068 ------------- 0	32,816 ------------- 0	62,491 ------------- 0	8,477 ------------- 0	12,299 ------------- 0	191,151 ------------- 0	0 ------------- 0
4James GouletVP Operations - Retired	(i) (ii)	165,362 ------------- 0	30,153 ------------- 0	18,000 ------------- 0	10,311 ------------- 0	24,418 ------------- 0	248,244 ------------- 0	0 ------------- 0
5Linda WallineVP Nursing	(i) (ii)	150,409 ------------- 0	27,661 ------------- 0	18,000 ------------- 0	7,570 ------------- 0	24,221 ------------- 0	227,861 ------------- 0	0 ------------- 0
6Michael HansenPresident/CEO/Secretary	(i) (ii)	347,285 ------------- 0	40,625 ------------- 0	18,000 ------------- 0	48,100 ------------- 0	26,405 ------------- 0	480,415 ------------- 0	0 ------------- 0
7Dustin Volkmer MDPhysician	(i) (ii)	463,906 ------------- 0	0 ------------- 0	0 ------------- 0	10,600 ------------- 0	26,348 ------------- 0	500,854 ------------- 0	0 ------------- 0
8Edward Fehringer MDPhysician	(i) (ii)	531,182 ------------- 0	110,676 ------------- 0	18,000 ------------- 0	10,600 ------------- 0	26,402 ------------- 0	696,860 ------------- 0	0 ------------- 0
9Mark Howerter MDPhysician	(i) (ii)	484,087 ------------- 0	0 ------------- 0	0 ------------- 0	10,600 ------------- 0	26,215 ------------- 0	520,902 ------------- 0	0 ------------- 0
10Michael McGuire MDPhysician	(i) (ii)	494,476 ------------- 0	29,557 ------------- 0	0 ------------- 0	10,600 ------------- 0	26,179 ------------- 0	560,812 ------------- 0	0 ------------- 0
11Richard CimplPhysician	(i) (ii)	490,012 ------------- 0	111,536 ------------- 0	18,000 ------------- 0	10,600 ------------- 0	26,348 ------------- 0	656,496 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
Schedule J, 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, Part I, Line 4b	The following reportable individuals participated in a supplemental nonqualified retirement plan during the 2015 calendar year. Amounts deferred from the plan were included in Column C of the Schedule J: Michael Hansen - $37,500 Amy Blaser - $10,080 Chad Van Cleave - $10,033
Schedule J, Part I, Line 3	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, and then decisions are documented.
Schedule J, Part I, Line 6a	With the assistance of Towers-Watson, executive compensation consultants, the Board authorized paying an incentive to the executives for meeting specific Board-Established Directives. The Board authorized paying up to 25% of base compensation for Michael Hansen and up to 20% for the following VPs: - James Goulet - Linda Walline - Amy Blaser - Chad Van Cleave The incentive is based on goals established by the Board which are now reviewed annually. One of the goals is the Hospital's operating margin. The Board determines the associated metrics for each individual goal. Each of the goals is then assigned a weight based on the level of importance, as determined by the Board. The results are entered and the metric is tabulated. That number is multiplied by the corresponding weight. Once weighted, the figures are added in total to establish a score between 1 and 5. No incentive is paid if the Hospital's operating margin falls below 5.0%, regardless of the outcomes of the other measures. Bonuses paid to physicians are based on productivity. The incentives were paid in this fiscal year for work done in the previous fiscal year. The bonuses paid were: - Michael Hansen - $40,625 - Richard Cimpl, MD - $111,536 - Edward Fehringer, MD - $110,676 - Michael McGuire, MD - $29,557 - Joe Barbaglia - $32,816 - Amy Blaser - $11,800 - James Goulet - $30,153 - Linda Walline - $27,661

Schedule J (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Columbus Community Hospital Inc

Employer identification number

47-0542043

Return Reference	Explanation
Form 990, Part VI, Line 11b	The Form 990 will be available for all the Members of the Finance Committee to review. Upon Committee review, the 990 will then be submitted to the full Board for review and the Board will make any corrections if applicable.
Form 990, Part VI, Line 12c	Columbus Community Hospital monitors any conflict of interest 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 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.
Form 990, Part VI, Line 15a	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. Decisions are documented.
Form 990, Part VI, Line 15b	The Hospital's CEO and Director of Human Resources, review the VP's and other highly compensated employee's compensation annually. The wage range is compared to information provided by third party consultants. Decisions are documented.
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: A) Governing Documents which are the Hospital's Bylaws B) Conflict of Interest Policy C) Audited Financial Statements D) Forms 990 and 990-T
Form 990, Part XI, Line 9	Other changes Change in interest in Healthpark LLC & ZARZ LLC 268,299

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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" on 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" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled 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 Company 4600 38th Street Columbus,NE68601 47-0830945	Holding Co	NE	501(C)(2)	N/A	CCH	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2015

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(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 V-UBI 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	Yes		44.450 %
(2) HealthPark LLC PO Box 1800 Columbus,NE68602 47-0836733	Property Mgmt	NE	Hlthpk Title Co	Related	0	0		No	0	Yes		27.210 %

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(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) 2015

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on 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) .......................

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) ............................

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) Columbus Community Hospital Foundation	c	539,702	Cash
(2) Healthpark Title Company	k	77,547	Book
(3) Healthpark Title Company	s	482,300	Cash

Schedule R (Form 990) 2015

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

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

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2015

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	10
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 2015 (Part V, line 2a) ......	5	710
6	Total number of volunteers (estimate if necessary) .............	6	246
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	20,886
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-43,973

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	209,336	562,546
9	Program service revenue (Part VIII, line 2g) .........	85,845,372	88,053,768
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	278,753	349,992
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	865,945	1,026,950
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	87,199,406	89,993,256
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	1,527,434	1,135,910
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)	38,405,724	40,237,051
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)....	32,675,999	35,305,130
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	72,609,157	76,678,091
19	Revenue less expenses. Subtract line 18 from line 12.......	14,590,249	13,315,165
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	100,393,386	114,831,604
21	Total liabilities (Part X, line 26).............	6,203,038	7,057,792
22	Net assets or fund balances. Subtract line 21 from line 20.....	94,190,348	107,773,812

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 73,095,628 including grants of $ 300 ) (Revenue $ 88,763,274 )
	Columbus Community Hospital (CCH) is a 47 bed acute care hospital which currently employs over 650 people. It is a significant, positive economic force for the Columbus area, returning dollars into the economy through local purchases by the organization and salaries that return to the community. It is an asset for the local communities where patients can obtain quality health care without the need to drive over 50 miles for care. CCH offers a variety of services that provide necessary care for area residents. Below is a brief summary of services offered by Columbus Community Hospital. - All 47 beds of the Hospital's acute care services are also certified as swing beds. - CCH provides certified, dedicated medical interpreters to assist non-English speaking patients. The interpreters are available in-house or on-call 24/7 and serve as a liaison between the care providers and the patient. - The Hospital provides ICU, medical surgical, OB and orthopedic services, along with a variety of complimentary ancillary services. These ancillary services include wound care, diabetic education and cardiac rehab and also include clinical pharmacy services. To enhance patient safety, CCH uses bar-coded medication administration, smart pumps and computerized physician order entry. - So that area residents can receive care close to home, CCH offers rehabilitative services that include physical therapy, speech therapy, occupational therapy as well as a driver's rehabilitation program. The Hospital's Wiggles and Giggles Therapy for Kids offers pediatric physical, occupational and speech for children ranging in age from babies to adolescents. In November 2012, the Hospital began offering the STAR cancer rehabilitation program, which includes physical, occupational and speech therapies. The STAR acronym stands for Survivorship, Training and Rehabilitation and CCH is one of only three hospitals in Nebraska to have achieved STAR program certification. The Hospital's program therapists are all certified through the STAR program. Over 74 STAR program referrals have been received through local providers, resulting in consultation for potential rehabilitation needs. In addition to physical, occupational and speech therapy, some of the participants have benefitted from nutritional consultations as well as psychosocial referrals. In addition, some of these patients have needed care for pulmonary issues and cardiovascular concerns. Several STAR participants have graduated from the program and transitioned into the Hospital's medical wellness program. - Nurses in the Hospital's Same Day Services (SDS) Department prepare patients for surgery and care for patients in both the inpatient and outpatient setting. The Department oversees several outpatient procedures, including 90 to 100 endoscopy procedures each month. SDS nurses also administer blood transfusions and chemotherapy infusions. - CCH offers some of the most advanced imaging services including MRI, CT, Digital Mammography and ultrasound. Radiologists are on campus and/or available 24/7. All images are digital, and the dictation used by radiologists is voice recognized and becomes part of the digital image. - The Hospital's laboratory performs an average of over 13,000 tests per month for both inpatients and outpatients. - The CCH Emergency Department (ED) employs highly trained emergency physicians and nurses, offering 24/7 care. Other Hospital departments providing support in the ED include Respiratory Care, Social Work, Laboratory, Medical Interpreters and Diagnostic Imaging. In May, 2006, the CCH Emergency Department was designated as a Level III Trauma Center. 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 trauma care and participates in injury prevention activities throughout the community. - CCH opened wound care services in August, 2008, offering clinic hours one day per week. The identified service area includes a 45-mile radius around Columbus. By January 2009, a second day was added to support the demand. The program has exceeded the anticipated demand and provides a much needed service close to home. The clinic sees about 100 patients per month for wound care. - For services located in facilities off-site, the larger services are Home Health and Hospice. Home Health provides skilled health services for patients at their place of residence. The program is medically directed and must be ordered by the attending physician. Home Health is Medicare and Medicaid Certified and meets the requirements of the Joint Commission. Services provided within the program are: - Supervision and administration of medications - Intravenous therapy - Instructing patients in diabetic management - Nutritional assessments - Home Health aides - Personal care services - Occupational, speech and physical therapies - 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. - The CCH Sleep Lab offers complete polysomnographic sleep testing by trained and licensed sleep technicians for the purpose of diagnosing obstructive/central sleep apnea. Both daytime and night sleep studies are performed. - 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 800 companies and with other health care professions, OHS provides the Columbus and regional area businesses and industry with a comprehensive range of services designed to support and maintain a healthy, safe workforce while assisting them in meeting OSHA and DOT compliance regulations. Their full range of services include: - A comprehensive testing procedure called Physical Capacity Profile (PCP) that 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. - 24/7 drug and alcohol testing services - Pre-employment/post job offer physical assessments - On-site nursing services - Hearing/vision testing - Hearing conservation program management - Respiratory fit testing - Respiratory evaluation services - Flu shots and immunization programs - Wellness programs - 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. Pre-determined responders are summoned to their home or emergency transfer can be call if needed. - 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 also participates in and has hosted county-wide natural disaster and pandemic drills. As a member of a larger preparedness team, RROMRS, CCH can assist or receive assistance from this region's Medicare providers. Through these drills and exercises, the Hospital is well-prepared to handle a natural disaster or pandemic should one arise.

4b	(Code: ) (Expenses $ 1,135,610 including grants of $ 1,135,610 ) (Revenue $ 0 )
	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 GREATER THAN $1,200, 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 expenses74,231,238

(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) Dustin Volkmer MD........................................................................ Physician	40.0 .......................0.0	X	463,906	0	32,622
(19) Edward Fehringer MD........................................................................ Physician	40.0 .......................0.0	X	659,858	0	32,622
(20) Mark Howerter MD........................................................................ Physician	40.0 .......................0.0	X	484,087	0	32,622
(21) Michael McGuire MD........................................................................ Physician	40.0 .......................0.0	X	524,033	0	32,622
(22) Richard Cimpl........................................................................ Physician	40.0 .......................0.0	X	619,548	0	32,622

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	4,157,126	0	415,633

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	539,702
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	22,844

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		562,546

			Business Code
2a	Net Patient Service Revenue	621110	87,475,747	87,475,747
b	Meaningful Use Payment	900099	578,021	578,021
c
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			88,053,768

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			266,172			266,172
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss)......			0
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	83,820
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	83,820
d	Net gain or (loss).....			83,820			83,820
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
Business Code			Miscellaneous Revenue
11a	Meals on Wheels		900099	58,359	58,359
b	Cafeteria		722514	296,558			296,558
c	Health Watch		900099	59,077	59,077
d	All other revenue ....			612,956	592,070	20,886
e	Total. Add lines 11a–11d ......			1,026,950
12	Total revenue. See Instructions......			89,993,256	88,763,274	20,886	646,550

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	300	300
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	1,135,610	1,135,610
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 ....	1,405,694		1,405,694
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	30,719,704	30,719,704
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,128,234	1,128,234
9	Other employee benefits .......	4,765,516	4,765,516
10	Payroll taxes ...........	2,217,903	2,217,903
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	67,519		67,519
c	Accounting ...........	151,017		151,017
d	Lobbying ...........	6,547		6,547
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)	3,249,349	3,249,349
12	Advertising and promotion ....	213,745		213,745
13	Office expenses .......	10,254,390	9,956,282	298,108
14	Information technology ......	1,756,092	1,756,092
15	Royalties ..	0
16	Occupancy ...........	1,675,681	1,675,681
17	Travel ............	195,511		195,511
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	108,712		108,712
20	Interest ...........	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	5,750,635	5,750,635
23	Insurance ...	288,911	288,911
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	5,429,402	5,429,402
b	Minor Equip & Financing AGR	2,223,518	2,223,518
c	Purchased Services	2,038,720	2,038,720
d	Recruiting	375,552	375,552
e	All other expenses	1,519,829	1,519,829
25	Total functional expenses. Add lines 1 through 24e	76,678,091	74,231,238	2,446,853	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).

1	Cash–non-interest-bearing ........			3,994,478	1	8,653,858
2	Savings and temporary cash investments .........			0	2	0
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			10,097,589	4	8,358,859
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	594,349
8	Inventories for sale or use ........			1,399,607	8	1,569,487
9	Prepaid expenses and deferred charges ......			1,918,503	9	1,853,872
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	115,891,454
b	Less: accumulated depreciation	10b	63,668,176	48,961,389	10c	52,223,278
11	Investments—publicly traded securities .			33,844,577	11	41,380,166
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 ...........			177,243	15	197,735
16	Total assets. Add lines 1 through 15 (must equal line 34)...			100,393,386	16	114,831,604

17	Accounts payable and accrued expenses .....	6,203,038	17	7,057,792
18	Grants payable ...	0	18	0
19	Deferred revenue .........	0	19	0
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	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..	6,203,038	26	7,057,792

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	94,190,348	27	107,773,812
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 ...........	94,190,348	33	107,773,812
34	Total liabilities and net assets/fund balances ........	100,393,386	34	114,831,604