TY 2018 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) Christie Obenauer...................................................................... President	2.00 .................	X	X		0	0
(2) Fred Stern...................................................................... Vice President	1.50 .................	X	X		0	0
(3) Myria Perry...................................................................... Secretary/Treasurer	1.50 .................	X	X		0	0
(4) Don Lyn Erickson...................................................................... Director	1.50 .................	X			0	0
(5) Mark Gerde...................................................................... Director	1.50 .................	X			0	0
(6) Robin Richter...................................................................... Director	1.50 .................	X			0	0
(7) Sienna Sailer...................................................................... Director	1.50 .................	X			0	0
(8) Beverly Huber...................................................................... Director	1.50 .................	X			0	0
(9) Todd Lindquist...................................................................... Director	1.50 .................	X			0	0
(10) Keith Johnson...................................................................... Director	1.50 .................	X			0	0
(11) Darrold Bertsch...................................................................... CEO	19.60 .................		X		151,060	78,000
(12) Renae Snyder...................................................................... CFO	40.00 .................		X		88,918	4,372
(13) Carl Miller...................................................................... CRNA	36.00 .................			X	150,534	29,479
(14) Alyssa Kelsch...................................................................... Pharmacist	40.00 .................			X	120,209	13,448
(15) Marcie Schulz...................................................................... Director of Patient Care	40.00 .................			X	109,541	26,885
(16) Michael Schmit...................................................................... Surgeon	40.00 .................			X	313,842	26,087
(17) Jen Hetzler...................................................................... Physical Therapist	40.00 .................			X	102,558	5,341

- 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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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 12, 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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

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) 2018

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv), 170(b)(1)(A)(vi), and 170(b)(1)(A)(ix)
(Complete only if you checked the box on line 5, 7, 8, or 9 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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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 2018 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2017 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2018. 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—2017. 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—2018. 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—2017. 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) 2018

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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 2018 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2017 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2018 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2017 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2018. 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—2017. 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) 2018

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d 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 12a or 12b 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) 2018

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) 2018

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 (explain in Part VI). 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) 2018

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 2018 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-2018	(iii) Distributable Amount for 2018
1 Distributable amount for 2018 from Section C, line 6
2 Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2018:
a From 2013.......
b From 2014.......
c From 2015.......
d From 2016.......
e From 2017.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2018 distributable amount
i Carryover from 2013 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2018 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2018 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2019. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2014......
b Excess from 2015.....
c Excess from 2016.....
d Excess from 2017.....
e Excess from 2018.....

Schedule A (Form 990 or 990-EZ) (2018)

Schedule A (Form 990 or 990-EZ) 2018

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) 2018

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.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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. Don't 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 isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018) Page 2

Name of organization Hazen Memorial Hospital Association

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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 3

Name of organization Hazen Memorial Hospital Association		Employer identification number 45-0308379

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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 4


Name of organization Hazen Memorial Hospital Association			Employer identification number 45-0308379
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) (2018)

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

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

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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 (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

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) 2018

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) 2015	(b) 2016	(c) 2017	(d) 2018	(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) 2018

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

2,789

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

2,789

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
Part II-B, Line 1:	The organization pays dues to NDHA and AHA and a portion of those membership fee is attributable to lobbying.

Schedule C (Form 990 or 990EZ) 2018

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.
SchDMd Bullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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 7/25/06, 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) 2018

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 ....	67,124	66,403	66,117	65,690	65,405
b	Contributions ...
c	Net investment earnings, gains, and losses	537	721	286	427	285
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......	67,661	67,124	66,403	66,117	65,690

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

73.900 %

Temporarily restricted endowment SchDMd Bullet

26.100 %

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)

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

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 .....	23,092		23,092
b	Buildings ....	27,154,741	4,753,340	22,401,401
c	Leasehold improvements
d	Equipment ....	7,335,362	2,755,245	4,580,117
e	Other .....	1,655,789	210,011	1,445,778
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				28,450,388

Schedule D (Form 990) 2018

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
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)
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) 2018

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	15,727,201
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	-848,641
e	Add lines 2a through 2d .....................			2e	-848,641
3	Subtract line 2e from line 1..................			3	16,575,842
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	10,980
c	Add lines 4a and 4b....................			4c	10,980
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	16,586,822

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	16,036,398
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	0
3	Subtract line 2e from line 1...................			3	16,036,398
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	550,371
c	Add lines 4a and 4b.....................			4c	550,371
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	16,586,769

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
Part V, Line 4:	The Medical Center's policy is to maintain sufficient financial stability for the operations of Medical Center. Interest income is to be transferred to the temporarily restricted endowment funds until the Board determines how the funds are to be used. In establishing this policy, the Medical Center considered the long-term expected return on its endowments. The spending policy states that distributions of earnings can be made if the Board of Directors deems it prudent to do so taking into account certain statutory factors included in the UPMIFA. Distributions may be made at least annually, but do not need to be done.
Part X, Line 2:	The Medical Center is organized as a North Dakota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Medical Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Medical Center is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Medical Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. The Medical Center believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Medical Center would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred.
Part XI, Line 2d - Other Adjustments:	Provision for Bad Debts Reported in Expenses on 990 -530,490. Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,151.
Part XI, Line 4b - Other Adjustments:	Net Auxiliary Revenue Not Included in Audited Financials 10,980.
Part XII, Line 4b - Other Adjustments:	Auxiliary Expenses Not Included in Audited Financials 19,881. Provision for Bad Debts Reported in Revenue on Audited Financials 530,490.

Schedule D (Form 990) 2018

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

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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? . . . . . .

Yes

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

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

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

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		(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) . . .	79,000		79,000	0.480 %
b	Medicaid (from Worksheet 3, column a) . . . . .	617,650	239,577	378,073	2.280 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	696,650	239,577	457,073	2.760 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	96,064		96,064	0.580 %
f	Health professions education (from Worksheet 5) . . .	66,564	18,485	48,079	0.290 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	65		65	0 %
j	Total. Other Benefits . .	162,693	18,485	144,208	0.870 %
k	Total. Add lines 7d and 7j .	859,343	258,062	601,281	3.630 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2018

Schedule H (Form 990) 2018

Page

Part II

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

		(a) Number of activities or programs (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	1	306	306	0 %
3	Community support	2	6,228	6,228	0.040 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy	9	15,794	15,794	0.100 %
8	Workforce development	3	778	778	0 %
9	Other
10	Total	15	23,106	23,106	0.140 %

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. ......

530,490

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. ......

26,524

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).....

7,171,100

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

7,282,715

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

-111,615

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 %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2018

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?1Name, 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)
1	Sakakawea Medical Center 510 8th Ave NE Hazen,ND58545 www.smcnd.org 5024A	X	X	X	X

Schedule H (Form 990) 2018

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)

	Hazen Memorial Hospital Association
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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

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

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 Pg 8 Supplemental Information

Other website (list url): See Pg 8 Supplemental Information

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 18

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

Yes

If "Yes" (list url): See Pg 8 Supplemental Information

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) 2018

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Hazen Memorial Hospital Association
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 100.000000000000% and FPG family income limit for eligibility for discounted care of 200.000000000000%

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)

Was widely publicized 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):

https://www.smcnd.org/assets/docs/caring_program_policy.pdf

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

https://www.smcnd.org/assets/docs/caring_program_policy.pdf

A plain language summary of the FAP was widely available on a website (list url):
https://www.smcnd.org/assets/docs/caring_program_policy.pdf

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)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 6

Part VFacility Information (continued)

Billing and Collections

	Hazen Memorial Hospital Association
Name of hospital facility or letter of facility reporting group

Yes

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 nonpayment?..................................

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

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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

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

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs

Made a reasonable effort to orally notify individuals about the FAP and FAP application process

Processed incomplete and complete FAP applications

Made presumptive eligibility determinations

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)

Schedule H (Form 990) 2018

Page 7

Part VFacility Information (continued)

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

	Hazen Memorial Hospital Association
Name of hospital facility or letter of facility reporting group

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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) 2018

Page 8

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, 16j, 18e, 19e, 20e, 21c, 21d, 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
Hazen Memorial Hospital Association	Part V, Section B, Line 5: Community surveys were conducted beginning in October 2018. Community meetings were held in October 2018 and March 2019. Additionally, key informant interviews were conducted in October 2018 by the Center for Rural Health. Organizations participating in the meetings included Sakakawea Medical Center, Coal Country Community Health Clinics, Knife River Care Center, Mercer County Ambulance, Southwestern District Health Unit, Hilltop Home of Comfort, and UND Center for Rural Health.
Hazen Memorial Hospital Association	Part V, Section B, Line 6b: Organizations participating include Coal Country Community Health Clinics, Knife River Care Center, Mercer County Ambulance, Southwestern District Health Unit, Hilltop Home of Comfort, and UND Center for Rural Health.
Hazen Memorial Hospital Association	Part V, Section B, Line 11: Due to the timing of the current CHNA and IS the organization was not able to address the needs identified in the most recent CHNA. In FY19 the organization addressed the needs identified in the last CHNA as follows:Projects and programs implemented to address needs identified in the 2016 Community Health Needs AssessmentAlthough meeting the healthcare needs of the communities we serve is a collaborative effort, each Local Health Provider involved in the collaborative CHNA and Implementation Plan has specific areas of expertise that govern their agency and the way they do business.Adequate child care services:Energy Capital Cooperative Child Care's (ECCCC) New Bethel Center opened on May 30, 2017 and was founded by eight employers that recognized the child care struggle that their employees and the community faced. ECCCC's founding partners include Sakakawea Medical Center (SMC); Coal Country Community Health Center (CCCHC); Knife River Care Center (KRCC); Dakota Gasification Company (lead agency); North American Coal Corporation; Union State Bank; Coyote Station; and Hazen Public Schools. The New Bethel Center is a licensed child care center with a capacity of 72 children ages infant to 12 years. The partners have guaranteed spots for their employees, but many spots are available for the members of the community as well. The center offers extended hours of operation to accommodate shift-working parents.Availability of behavioral health services (mental health & substance abuse/treatment):CCCHC spearheads the effort to address mental health and substance abuse issues and relies on the partners to assist by providing additional resources for programming, education, as well as tapping into financial and staffing availability. In addition, CCCHC, SMC & KRCC continue to screen all clinic, emergency room, hospital, basic care, long term care and visiting nurse admits for depression by incorporating the PHQ2 and PHQ9 screening criteria for all initial patient encounters. Should a patient screen positive on the PHQ9, referrals are made for appropriate follow-up and/or intervention.Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and behavioral therapies for the treatment of addiction/substance use disorders; and can help some people to sustain recovery. CCCHC offers and has expended the MAT program offered to three days per week in Beulah and two days per month at Killdeer.With the increase in demand for Drug & Alcohol Evaluation and Intervention, an additional full-time Licensed Addiction Counselor (LAC) was hired by CCCHC in 2018. The additional staffing of a LAC allows Substance Use Disorders, as-well-as Mental Health services to be available daily at the CCCHC Beulah Clinic. CCCHC anticipates that two additional part-time LAC's will begin employment in the Spring of 2019 upon completion of construction of a new behavioral health unit facilitating expansion of services and co-location with primary care. CCCHC also partners with several organizations through a consortium for training addiction counselors in both rural and urban ND. TAAP, Training Academy of Addiction Professionals, prepares addiction trainees to demonstrate minimum competence and skill set for addiction counseling leading to a LAC. In addition, CCCHC has increased the availability of visiting psychologists from four days per month to six days per month in Beulah and is currently exploring tele-behavioral health services to assist in meeting the additional needs of the community.Custer Health manages and operates a syringe exchange program (SEP) in North Dakota called the "Mandan Good Neighbor Project". The program is a community-based public health program that provides comprehensive harm reduction services for people who inject drugs (PWID). In addition to needle exchange, Custer Health has provided training and Nasal Narcan (when available) for local law enforcement to include the City of Beulah and the Oliver County Sheriff's Department.In 2016-2017, Beulah Public School District contacted CCCHC for assessment and assistance with behavioral health for the school and a pilot project was implemented for case management of behavioral health issues within the walls of the school. The project increased access to students in grades K - 12. Since then, CCCHC is facilitating resource mapping and development framework for sustainability and replication of the program in additional school districts for the 2019-2020 school year. Integrating Mental Health Physical Health and Continuity of Care Together (IMPACT) program, has been implemented within the Beulah School District to include the purchase of a license to implement BIMAS-2. BIMAS-2 offers Universal Screening through an online web-based data management system that measures social, emotional and behavioral functioning in youth and adolescents, and allows users to manipulate data in real time to assist in evidence-based decision-making within a comprehensive behavior health care model of service delivery. Areas assessed within the BIMAS-2 include conduct, negative affect, cognitive/attention, social and academic functioning. Beulah School District has now completed 75% of all Universal Screenings. In addition, a needs assessment was completed with the Hazen School District and a license for BIMAS-2 purchased with the implementation of IMPACT; Universal Screening is now in progress for the Hazen School District.Additionally, education and training has been delivered for the implementation of a Multi-tiered Systems of Support (MTSS) for youth and adolescents. MTSS is a framework used to provide targeted support to struggling students. It focuses on the "whole" child and supports academic growth and achievement including behavior, social and emotional needs, and attendance. Joint Task Force meetings have been implemented between Beulah and Hazen School Districts with CCCHC's team for further implementation of the IMPACT program. A full-time LSW/IMPACT Program Coordinator is providing care coordination and case management for Beulah and will be expanding into Hazen in 2019. A Psychologist and LICSW are currently providing mental health services at the Beulah School District as part of MTSS.Lack of employees to fill positions:All agencies are addressing the workforce shortage by actively supporting local programs such as the Dakota Practical Nursing Program that is offered in Hazen. The Dakota Nursing Program allows local individuals to achieve a personal career goal through non-traditional means and eliminates the need for students to travel away from home to obtain a career in nursing. The program directly address the region's nursing workforce shortage and is offered through Bismarck State College. During the program, students are on campus at SMC four days a week. Clinicals begin in December and go through the completion of the program in July and are held at multiple healthcare facilities within the area, providing students with the best learning experience possible. Since the implementation of the program in 2012, 25 students have graduated with an additional 3 students that will potentially graduate in the Summer of 2019.Each Local Health Provider within the collaborative actively participates to present health occupations at the Dunn, Mercer and Oliver County Scrubs Camp which is a one-day, hands-on opportunity for high school students designed to increase awareness, interest, and understanding of health careers available. Through creative and interactive activities, Scrubs Camp provides an opportunity for students to experience first-hand, the challenges, opportunities and rewards of health careers while learning about the skills and education that are required to become a health professional.In order to increase efficiency in hiring and retention and to ensure consistency and compliance in the recruitment and selection process, a collaborative effort between SMC, CCCHC & KRCC has resulted in the combining of resources to provide for a Shared Human Resource professional that coordinates the recruitment of professional health care staff for the area and administers formal agreements initiated with recruitment firms for physicians.Furthermore, SMC and CCCHC have partnered together to locally facilitate the Medical Assistant program offered through Dakota College at Bottineau and had two Medical Assistants graduate in the summer of 2016. One of the Medical Assistants is currently employed full-time at CCCHC.In 2018, CCCHC hired two additional full-time mid-level family practice providers to their team of health care professionals. Kelsey Striefel, DNP, is practicing at the CCCHC Hazen Clinic; and Kayla Ternes, PA-C, sees patients at the CCCHC Beulah Clinic site.
Hazen Memorial Hospital Association	Part V, Section B, Line 13h: Sakakawea Medical Center offers two separate programs for discounted care. The self-pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 30% to 100% of charges. The program is available for uninsured patients as well as co-pays and deductibles for insured patients.The self-pay discounts program cannot be combined with the charity care program. However, the Hospital counsels all self-pay individuals to determine if their potential charity care discount would result in a better discount if they apply for charity care. The patients that use the self-pay discount are typically the patients that do not want to submit their financial information or patients that would not qualify under the charity care policy.
Hazen Memorial Hospital Association	Part V, Section B, Line 15e: An individual must complete an application and submit supporting documentation such as check stubs or an income tax return. All of the staff in the Business Office billing department are able to assist individuals with any questions they have regarding the application process.
Hazen Memorial Hospital Association	Part V, Section B, Line 16j: In addition to the full FAP being available upon request, information referencing the FAP is attached to the billing invoices, as well as posted in the admissions office, emergency rooms and waiting rooms.
Schedule H, Part V, Line 11 continued...	Obesity/overweight:Physical inactivity, obesity and overweight are being addressed cooperatively and with individual campaigns. All of the Local Health Providers offer Worksite Wellness Programs for employees and their families. In addition, CCCHC, SMC and Custer Health participate in corporate and community wellness events by offering health screenings, health awareness and educational seminars for individuals and community groups. On April 30, 2018 the Energy Wellness Center opened in Beulah, ND and offers a full range of activities to include wellness and fitness classes for individuals and groups. The state-of-the-art facility enables the community to become healthier in all aspects of life and provides year-round recreation to the citizens of the tri-county area delivering new exercise and education programs for the community. Amenities include basketball court, cardio deck, community room, daycare, golf simulator, group exercise studio, lobby, locker rooms, racquetball court, indoor walking/running track, and weight room.In an effort to improve the overall health of the population that we serve, the Local Health Providers continue to facilitate the Population Health Committee with representatives from each agency where the main objective is to improve population health through innovative and engaging projects. Through the Population Health Committee, the "JumpStart to Wellness" campaign was implemented and remains strong, addressing obesity and physical activity with various successful projects facilitated throughout the year (5K Color Walk/Run, Healthy Halloween Bash, Women's World of Wellness, Mercer County Fair, Mercer County parade, etc.).Breastfeeding has been identified as one of the six focal points of the CDC's Childhood Obesity Prevention Plan identifying that the duration of exclusive breastfeeding was inversely associated with the risk of elevated weight gain. To engage young families and teach successful breastfeeding techniques, local public health has trained a public health nurse as a CLC (Certified Lactation Consultant). The CLC provides counseling and lactation management during WIC, Beyond Birth Education, and Maternal and Child Health services.Transportation:Access to transportation contributes to the economic development, health, and quality of life of rural communities. Reliable transportation is needed for rural residents to access healthcare services, employment and educational opportunities, and social services. It is also important for accessing recreation and other activities of daily life. Though the Local Health Providers do not have the resources or expertise to address all transportation needs, we have come up with some viable solutions to address the transportation needs for patients seeking local healthcare services.CCCHC offers free transportation services to and from appointments at the Hazen and Beulah Clinic sites; with a full-time driver on staff, CCCHC owns and operates three agency vans. Patients can schedule transportation services when they schedule their next appointment.SMC works cooperatively with local transportation services to provide patients with vouchers that can be used for free rides to and from the medical center; once the patient uses the voucher, the transportation service turns the voucher into SMC for payment. SMC works with West River Transit to provide transportation services for the Beulah and Center communities, while Hazen Busing serves the community of Hazen. Delivery and availability of Health Services to include expanded appointment hours and cost of health care services:Patient Centered Medical Home (PCMH) model of healthcare has been incorporated into the operations of both SMC & CCCHC. The PCMH model proposes to improve primary care by focusing on the patient- provider relationship and strengthen this dynamic though a more comprehensive team approach to patient care and more active patient involvement. PCMH provides comprehensive care coordination to all patients at all points of care whether seen in the ER, admitted to the hospital, or seen in the clinics for primary care. A comprehensive care coordination committee has been formed by the Local Health Providers and meets monthly to review repeat admission and repeat ER visits with care coordination intervention from Custer Health, SMC, KRCC, and CCCHC including Community Care Coordination. Outcome data signifies a decrease in BCBS and Medicare unnecessary ER visits and potentially preventable admissions. The Local Health Providers continue to expand and enhance a Patient Centered Medical Neighborhood of care delivery throughout the tri-county service area. Health Tracks, a public health program, is for children birth-20 years of age who are on Medicaid. It is a preventive health program that can pay for many things including counseling, hearing and vision care, developmental screenings, immunizations, lab tests, dental care, and referrals to specialists. In 2018, Custer Health enhanced the community engagement of this program and increased their Health Tracks screenings by 58%.In addition, Custer Health and CCCHC have increased the provision of immunizations by working together to offer immunization clinics for students during local Parent/Teacher Conferences. Upon the completion of two successful years, Custer Health and CCCHC have expanded the program and now offer both fall and spring clinics for the Beulah and Hazen School Districts.FluFIT programs increase colorectal cancer screening rates by providing a take home fecal immunochemical test (FIT) to eligible patients when they receive their annual flu shot. Therefore, the annual flu shot campaign creates an opportunity to reach people who are also due for colorectal screening. Custer Health in conjunction with CCCHC and local area pharmacists, provide the FluFIT kits during October flu shot clinics offered within the service area. In 2018, 89 patients were screened on FluFit clinic day.To help remove barriers to the delivery and availability of health services, CCCHC is expanding the Beulah Clinic site. When completed, this project will enhance the way CCCHC provides medical care by doubling the clinic space to accommodate patient and staff needs. The expansion will also allow CCCHC to co-locate behavioral health and primary care and host additional visiting specialists to the area. The anticipated completion date of the clinic expansion is June 2019. In addition, CCCHC has extended clinic hours available for appointments. CCCHC Beulah Clinic now sees patients beginning at 7:30 a.m. on Mondays and Wednesdays. Phone lines are open at 7:00 a.m. for patients to call providing enhanced primary care access.
Schedule H, Part V, Line 7a/b and Line 10 URL Links:	Line 7a:https://www.smcnd.org/assets/docs/community_health.pdfLine 7b:https://coalcountryhealth.com/assets/docs/community_health.pdfLine 10:https://www.smcnd.org/assets/docs/implementation_plan.pdf

Schedule H (Form 990) 2018

Page 9

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?1
Name and address		Type of Facility (describe)
1	1 - Senior Suites at Sakakawea 813 7th St NE Hazen,ND58545	Basic Care Facility
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2018

Page 10

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
Part I, Line 3c:	Sakakawea Medical Center offers two separate programs for discounted care. The self pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. This program cannot be combined with the Charity Care program.The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 30% to 100% of charges. The program is available for uninsured patients as well as co-pays and deductibles for insured patients.
Part I, Line 7:	Charity care is based on the total direct and indirect costs related to providing services to patients and based on average ratios of cost to charges. Unreimbursed Medicaid was converted to cost using the cost-to-charge ratio derived from the relevant cost center on the Medicare cost report. Community health improvement services, health professionals education, and cash and in-kind contributions for community benefit reflect actual expenses recorded to the general ledger.
Part II, Community Building Activities:	The CEO serves on one board for economic development - Mercer County Economic Development, one board for community support - Energy Capital Child Care Cooperative, six boards for community health improvement advocacy - Community Health Association of the Mountain Plains States, Caravan Health, North Dakota Hospital Association, Area Health Education Center, Knife River Care Center, and Community Healthcare Association of the Dakotas. The Director of Patient Care serves on four boards - Bismarck State College Advisory Board, University of Mary Advisory Board, ND Governor's Nursing Workforce, and North Dakota CAH Quality. The CFO, Surgeon, and Nurse Coordinator all serve on the Mercer County Ambulance Board. The HIM Director serves on the Dakota Central Social Service Board.
Part III, Line 2:	Bad debt expense is reported at charges. Payments and discounts are posted to patient bills.
Part III, Line 3:	There are most likely some patients in bad debt who would qualify for charity care, but they have not completed the application and remitted the required payment. We used charity care as a percentage of total revenues to figure that the estimated amount of bad debt expense that is attributable to patients eligible under the organization's financial assistance policy would be approximately $26,524.
Part III, Line 4:	The footnote to the Organization's financial statements can be found on pages 9 and 10 of the attached audited financial statements.
Part III, Line 8:	Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare & Medicaid Services. The costs themselves are a community benefit as the community would not receive these services if we did not provide them.
Part III, Line 9b:	If a patient has applied for charity care previously, an application is sent with the monthly statement. Once it is determined that the patient is eligible, the charity care discount portion is written off. The organization does not send patient accounts to collections within the first 120 days of the date of the first invoice for a service. The organization allows the patient up to 240 days from the date of the first invoice for that service to complete the charity care application. If the patient account is with the collection agency within the 240 days of the first invoice and it is determined they qualify for charity care, the organization will notify the collection agency of the amount of charity care that applies to the account. The remaining patient portion then falls under the same collection practices of all other accounts. Our policy requires a new charity care application every six months.
Part VI, Line 2:	Sakakawea Medical Center consults with local physicians to identify community healthcare needs. The SMC staff participates in local and regional organizations and activities including Chamber of Commerce and economic development boards. The CEO routinely attends city council and county commission meetings to solicit input and engage in dialogue relating to healthcare needs and services.Sakakawea Medical Center has collaborated with other local providers to conduct a community health needs assessment which will inventory service delivery assets, identify needs and create a foundation for undertaking strategic initiatives.
Part VI, Line 3:	Charity care information is sent with the monthly statements to all uninsured patients as well as patients that are not making adequate monthly payments. Approximately 100 notices are sent out per month with the statements. Inpatients and surgical patients are informed at time of admission about charity care. A social worker visits with all self-pay inpatients to inform them about the charity care, Medicaid (state program), and self-pay discount policies. Brochures have been printed that describe our charity care and discount policies. The brochures are available in waiting rooms, ER, the clinics and admitting offices. In addition to these efforts, the financial assistance policy is also available on the website.
Part VI, Line 4:	Sakakawea Medical Center serves the communities in Mercer County and the surrounding area, including the towns of Hazen, Beulah, Stanton, Zap, Golden Valley, Center and Pick City. Sakakawea Medical Center, located in Hazen, is the only hospital in the county. The nearest hospital is located more than 60 miles away. Attached to the hospital is Senior Suites, a basic care facility. The combined total population of the county is approximately 8,685. The average per capita income in Mercer County for 2019 was $38,441. The current unemployment rate is 3.9%. Sakakawea Medical Center's payer mix for this fiscal year included 6% uninsured patients and 3% Medicaid patients. All patients presenting to the facility are cared for regardless of their ability to pay.
Part VI, Line 5:	As a critical access hospital, Sakakawea Medical Center provides a variety of health and wellness services to our service area. The organization subsidizes home care services to ensure those residents who are homebound have the health care they need. The emergency room is staffed 24 hours a day and is available to all regardless of ability to pay. The Board of Directors is comprised of county-wide volunteers; four are from Hazen, five from Beulah, and one from Stanton. The directors have various occupations including power plant manager, bank president, accounting supervisor, engineer, chiropractor, and business owner. The directors are not employed by SMC.Medical privileges are extended to all physicians in the county.Sakakawea Medical Center's Hospice staff is assisted by 58 volunteers from the area communities. The staff at Senior Suites, the basic care facility, is served by 30 community volunteers. Surplus funds are invested back into the facility through equipment purchases and facility improvements. This past year, SMC installed a Med Vac line and processing sink in the OR. Other equipment purchases included a hospice bed, a ventilator for Respiratory Therapy, Physical Therapy equipment and cardiac stress test equipment. SMC also purchased EPIC, an electronic medical record system, this included computers and various support software. Future surplus funds will be used to meet debt service requirements and any needed equipment additions or replacements. In addition, more continuing education is being offered to the staff by means of webinars and workshops. An employee assistance program is available for staff and family members which provides free confidential assessments, counseling, or referral services by trained professionals.Sakakawea Medical Center is investing in the future of healthcare professionals by implementing a nursing program. We are partnering with other health care providers in the county, a community health center and a nursing home, to offer Interactive Video Network (IVN) classes in our facility. Hands-on skill work and clinicals are taught by registered nurses employed by our organization. Upon completion of an 11 month program, students will receive a certificate in practical nursing. An additional 9 month program enables the students to receive an Associate Degree in Nursing and become eligible to test for their registered nurse license. Sakakawea Medical Center also supports state universities and high schools by offering rural medical experiences to area students. Throughout the year, students are provided with practice opportunities in nursing, lab, PT or the emergency room.Beginning in 2015, Sakakawea Medical Center is also assisting the Dakota College at Bottineau, ND with their Medical Assistant Program. Students study through on line courses provided by Dakota College. The hands-on skills are taught by registered nurses in our facility weekly. Students can complete a one year program for a diploma, or a two year program for a degree.

Schedule H (Form 990) 2018

Additional Data

Software ID:
Software Version:

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization
Hazen Memorial Hospital Association

Employer identification number
45-0308379

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 noncash assistance	(h) Purpose of grant or assistance
(1) Sakakwea Medical Center Foundation 510 8th Ave NE Hazen,ND58545	45-0453816	501(c)(3)	15,000				Cardiac Rehab Equipment and Senior Suites Furniture

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) 2018

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 noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(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
Part I, Line 2:	Fund are set aside in the Sakakwea Medical Center Foundation for specific purposes. Those funds are then requested by SMC to help purchase those items. SMC pays the vendors for the equipment. The Auxiliary is a part of SMC financial reporting on the Form 990. In the fiscal year the Auxiliary provided the grant to the Foundation. The Foundation then provided the funds back to SMC.

Schedule I (Form 990) 2018

Additional Data

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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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

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 .........

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? ..

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

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 nonfixed
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) 2018

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)
1Darrold Bertsch CEO	(i) (ii)	151,060 ------------- 0	0 ------------- 0	0 ------------- 0	78,000 ------------- 0	0 ------------- 0	229,060 ------------- 0	0 ------------- 0
2Carl Miller CRNA	(i) (ii)	141,216 ------------- 0	0 ------------- 0	9,318 ------------- 0	6,694 ------------- 0	22,830 ------------- 0	180,058 ------------- 0	0 ------------- 0
3Michael Schmit Surgeon	(i) (ii)	313,842 ------------- 0	0 ------------- 0	0 ------------- 0	11,000 ------------- 0	15,132 ------------- 0	339,974 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2018

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

Part I, Line 4b

SMC paid $78,000 in premiums for a 457(f) plan for Darrold Bertsch, CEO. This amount is reflected in Schedule J, Part II, deferred compensation.

Schedule J, Part II:

Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Schedule J, Part II reflects total base compensation, benefits and payroll taxes associated with this compensation on which SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2018 Form W-2 from CCCHC. In the calendar year 2018, Darrold received $151,060 from CCCHC related to the reimbursement of his services as SMC CEO. The deferred compensation reported in Part II are in relation to the 457(f) plan premiums SMC paid on his behalf. This deferred compensation is not included in the amount SMC reimburses CCCHC.

Schedule J (Form 990) 2018

Additional Data

Software ID:
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- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No
(1) Union State Bank (USB)	Family ownership >35% of Union State Bank through Hazen Bancorporation HC	PACE Loan	X		10,258,000	9,430,283		No	Yes		Yes





Total ............... $						9,430,283

Part III

Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2018

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) Jocelyn Bertsch	Wife of CEO	70,763	Employee Compensation		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2018

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Hazen Memorial Hospital Association

Employer identification number

45-0308379

Return Reference	Explanation
Form 990, Part VI, Section A, line 1	There were 10 board of directors at fiscal year end, but the board president only votes to break a tie. The Executive Committee shall consist of the President, Vice President and Secretary/Treasurer of the Board. The CEO of the corporation shall serve without voting powers. The Executive Committee shall have the power to transact all business of the corporation during the interim between meetings of the Board of Directors, provided that any action so taken shall not conflict with the policies and express wishes of the Board of Directors, and that it shall refer all matters of major importance to the full Board of Directors. This committee shall meet as required. In the current fiscal year, the Executive Committee did not meet to make any decisions on behalf of the full governing board.
Form 990, Part VI, Section A, line 6	Any person, firm, association, or corporation interested in the activities of this organization, and residing in the service area, may become a member thereof, provided that he has first made a contribution to the association at some time. Each member has one voting right.
Form 990, Part VI, Section A, line 7a	The members elect the Board of Directors on an annual basis.
Form 990, Part VI, Section A, line 7b	The members must also approve/disapprove the dissolution of the organization or the merger or consolidation of the organization with another corporation.
Form 990, Part VI, Section A, line 8b	All items discussed at committee meetings are brought to the full board for recommendations for board action. The organization did not have any committees that acted on behalf of the board.
Form 990, Part VI, Section B, line 11b	Upon receipt of the draft Form 990, a copy will be forwarded to the board members for their review and comment.
Form 990, Part VI, Section B, line 12c	The Board of Directors is covered by the conflict of interest policy. Only one conflict has been disclosed this fiscal year by a member of the Board of Directors. The director who has acknowledged the conflict of interest is excused from the board meeting whenever there is discussion about the relevant issue. Although the written policy as of June 30, 2016 did not address the officers of the organization, the officers do review and comply with the policy and disclose to the board of directors if a conflicts does exist. After the conflict is self-reported that officer abstains completely from the decision process of the issue at hand.
Form 990, Part VI, Section B, line 15	The CEO was paid by an unrelated organization that annually used comparability data to review and determine his compensation. The decision was made by the Board of Directors from both the unrelated organization and Sakakawea Medical Center. For purposes of determining the CFO's compensation package at Sakakawea Medical Center, a variety of resources are used. The Organization takes into consideration what is appropriate compensation for that respective position, based on their market. The Organization uses salary surveys from the North Dakota Hospital Association and also refers to the public 990 information from similar sized hospitals in North Dakota. The CFO is evaluated by the CEO annually and the compensation is based on the above information.
Form 990, Part VI, Section C, line 19	The Organization's governing documents, conflict of interest policy, and financial statements are available if specifically requested.
Form 990, Part VII:	Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Schedule J, Part II reflects total base compensation, benefits and payroll taxes associated with this compensation on which SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2018 Form W-2 from CCCHC. In the calendar year 2018, Darrold received $151,060 from CCCHC related to the reimbursement of his services as SMC CEO. The deferred compensation reported in Part II are in relation to the 457(f) plan premiums SMC paid on his behalf. This deferred compensation is not included in the amount SMC reimburses CCCHC.
Form 990, Part IX, line 11g	Medical Purchased Services: Program service expenses 1,796,673. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,796,673. Other Purchased Services: Program service expenses 74,582. Management and general expenses 91,936. Fundraising expenses 0. Total expenses 166,518.
Form 990, Part XI, line 9:	Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,151. Change in Net Assets of Hazen Memorial Hospital Auxiliary 8,901.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2018

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	802,103	586,051
9	Program service revenue (Part VIII, line 2g) .........	15,925,629	15,796,940
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	24,459	70,150
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	148,053	133,681
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	16,900,244	16,586,822
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	4,500	18,000
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)	7,763,089	8,115,306
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)....	8,015,771	8,453,463
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	15,783,360	16,586,769
19	Revenue less expenses. Subtract line 18 from line 12.......	1,116,884	53
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	40,840,371	39,206,345
21	Total liabilities (Part X, line 26).............	28,881,050	27,556,221
22	Net assets or fund balances. Subtract line 21 from line 20.....	11,959,321	11,650,124

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 12,862,498 including grants of $ 18,000 ) (Revenue $ 14,388,643 )
	Sakakawea Medical Center (SMC) is a 13 bed critical access hospital providing services in the following areas - acute care, observation, surgery, intermediate and skilled swing bed, emergency room with trauma level V certification, Saturday convenience clinic, and hospice. Services provided by the ancillary departments include physical therapy, occupational therapy, radiology, 3D mammography, bone density, ultrasound, CT, nuclear med, MRI, laboratory, respiratory therapy, cardiac rehab, EKG, Holter Monitor, and thallium stress tests. Based on charges foregone Sakakawea Medical Center provided $67,869 in charity care. Also available to all self-pay patients, regardless of financial status, is a 30% discount policy for timely payments. SMC is a participating provider for Medicare, Medicaid, Blue Cross Blue Shield and other insurances.Sakakawea Medical Center reaches out to the communities in the service area through programs such as falls prevention classes, CPR education, ACLS classes, PALS classes, grief support groups, smoking cessation classes, occupational health, free blood pressure checks, a Christmas giving tree project, a Community Care nurse and health career presentations to high schools. SMC sponsors several community events that promote good health and wellness education including Healthy Halloween Bash, Women's World of Wellness and Mammography Marathon. Wellness screenings are provided to area schools and businesses. SMC provides community education programs on requested topics free of charge. It is important for Sakakawea Medical Center to serve our communities by providing all of their health care needs.

4b	(Code: ) (Expenses $ 1,061,101 including grants of $ ) (Revenue $ 1,408,297 )
	Senior Suites is a basic care facility that was completed in April 1997. It is adjacent to Sakakawea Medical Center. Senior Suites can accommodate 34 residents with single or double rooms. It features a licensed beauty shop, activity room, spacious commons areas and an enclosed nurse's station. The rooms are set up like suites, hence the name "Senior Suites." The facility is available to those in the senior population that require a minimal amount of supervision, but do not require 24 hour services. The residents are provided with assistance for daily living and medication administration. Resident care census days totaled 9,872 this year.

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses13,923,599

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,036,662	0	183,612

(A) Name and business address	(B) Description of services	(C) Compensation
Dr Thomas Kaspari MD PC, 1351 51st Ave SW Hazen,ND58545	ER Physician Services	136,870




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 1

1	Briefly describe the organization’s mission or most significant activities: To be the preeminent providers of innovative and collaborative healthcare services.
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	9
5	Total number of individuals employed in calendar year 2018 (Part V, line 2a) ......	5	175
6	Total number of volunteers (estimate if necessary) .............	6	88
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	11,600

f	All other contributions, gifts, grants, and similar amounts not included above		1f	574,451

g	Noncash contributions included in lines 1a - 1f:$
h Total. Add lines 1a-1f.......		586,051

		Business Code
2a	Patient and Resident Services	621400	15,378,490	15,378,490
b	Other Program Revenue	623000	294,896	294,896
c	Cafeteria	623000	72,642	72,642
d	Education	623000	50,912	50,912
e
f	All other program service revenue.
g	Total. Add lines 2a–2f ....		15,796,940

3 Investment income (including dividends, interest, and othersimilar amounts) ......			73,742			73,742
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		126,748
b	Less: rental expenses		0
c	Rental income or (loss)		126,748
d	Net rental income or (loss)......			126,748			126,748
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses	3,592
c	Gain or (loss)	-3,592
d	Net gain or (loss).....			-3,592			-3,592
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a		8,996
b	Less: direct expenses ...b		2,063
c	Net income or (loss) from fundraising events..			6,933			6,933
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..
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..
Business Code			Miscellaneous Revenue
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......
12	Total revenue. See Instructions......			16,586,822	15,796,940	0	203,831

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	15,000	15,000
2	Grants and other assistance to domestic individuals. See Part IV, line 22	3,000	3,000
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, line 15 and 16.
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	325,473		325,473
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	70,763		70,763
7	Other salaries and wages	6,480,593	5,973,744	506,849
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	207,579	192,369	15,210
9	Other employee benefits .......	555,103	501,023	54,080
10	Payroll taxes ...........	475,795	426,628	49,167
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........	69,498		69,498
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	1,963,191	1,871,255	91,936
12	Advertising and promotion ....	33,557		33,557
13	Office expenses .......	286,981	129,582	157,399
14	Information technology ......	104,318		104,318
15	Royalties ..
16	Occupancy ...........	663,592	639,999	23,593
17	Travel ............	63,672	59,230	4,442
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........	448,224	331,463	116,761
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	2,394,725	1,770,909	623,816
23	Insurance ...	223,562	8,343	215,219
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	Medical Supplies	1,225,685	1,225,685
b	Bad Debt Expense	530,490	530,490
c	Food	149,736	149,736
d	Dues & Subscriptions	75,540	52,285	23,255
e	All other expenses	220,692	42,858	177,834
25	Total functional expenses. Add lines 1 through 24e	16,586,769	13,923,599	2,663,170	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 ........			8,322	1	3,876
2	Savings and temporary cash investments .........			5,780,341	2	5,259,542
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			1,560,593	4	1,920,354
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .............
					5
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 ..............
					6
7	Notes and loans receivable, net ....				7
8	Inventories for sale or use ........			366,543	8	332,580
9	Prepaid expenses and deferred charges ......			91,491	9	112,368
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	36,168,984
b	Less: accumulated depreciation	10b	7,718,596	30,355,028	10c	28,450,388
11	Investments—publicly traded securities .			600,845	11	1,224,525
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..			1,435,677	13	1,117,526
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			641,531	15	785,186
16	Total assets. Add lines 1 through 15 (must equal line 34)...			40,840,371	16	39,206,345

17	Accounts payable and accrued expenses .....	858,389	17	955,686
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	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..	9,648,354	22	9,430,283
23	Secured mortgages and notes payable to unrelated third parties ..	17,774,307	23	17,170,252
24	Unsecured notes and loans payable to unrelated third parties ..		24
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	600,000	25	0
26	Total liabilities. Add lines 17 through 25..	28,881,050	26	27,556,221

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	10,456,520	27	10,464,937
28	Temporarily restricted net assets ...........	1,452,801	28	1,135,187
29	Permanently restricted net assets	50,000	29	50,000
	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 ...........	11,959,321	33	11,650,124
34	Total liabilities and net assets/fund balances ........	40,840,371	34	39,206,345