SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
POUDRE VALLEY HEALTH CARE INC
 
Employer identification number

84-1262971
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
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:
3a
Yes
 
b
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: . . . . . . . .
3b
Yes
 
%
c
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.
4
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"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . .
    759,922   759,922 0.180 %
b Medicaid (from Worksheet 3, column a) . . . . .     61,689,920 50,887,549 10,802,371 2.560 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .     20,652,344 20,567,826 84,518 0.020 %
d Total Financial Assistance and Means-Tested Government Programs . . . . .     83,102,186 71,455,375 11,646,811 2.760 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     2,417,945 177,800 2,240,145 0.530 %
f Health professions education (from Worksheet 5) . . .     5,644,690 1,040,346 4,604,344 1.090 %
g Subsidized health services (from Worksheet 6) . . . .     9,016,258 6,065,985 2,950,273 0.700 %
h Research (from Worksheet 7) .     1,057,678 213,539 844,139 0.200 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     31,289,872   31,289,872 7.410 %
j Total. Other Benefits . .     49,426,443 7,497,670 41,928,773 9.930 %
k Total. Add lines 7d and 7j .     132,528,629 78,953,045 53,575,584 12.690 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue
(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development     200   200 0 %
3 Community support     81,338   81,338 0.020 %
4 Environmental improvements     1,000   1,000 0 %
5 Leadership development and training for community members     1,245   1,245 0 %
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other     150,370   150,370 0.040 %
10 Total     234,153   234,153 0.060 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
23,781,564
3
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. ......
3
 
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
137,860,111
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
176,974,237
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-39,114,126
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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 .........................

9b

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 %
11 HARMONY SURGERY CENTER LLC
 
AMBULATORY SURGERY 50.000 %   50.000 %
22 PEAK SURGICAL MANAGEMENT
 
MANAGEMENT SERVICES 14.000 %   86.000 %
33 HARMONY IMAGING CENTER LLC
 
MEDICAL IMAGING 46.000 %   54.000 %
44 SURGERY CENTER OF FORT COLLINS
 
AMBULATORY SURGERY 26.000 %   49.000 %
55 GATEWAY MEDICAL SERVICES
 
REAL ESTATE/MEDICAL EQUIPMENT 50.000 %   50.000 %
66 EYE AND LASER CENTER OF NORTHERN COLO LLC
 
LASER SURGERY 50.000 %   50.000 %
77 VEIN AND LASER CENTER OF N COLO
 
LASER SURGERY 33.000 %   67.000 %
88 PVHS-ICM EHW LLC
 
MEDICAL CLINIC 50.000 %   50.000 %
9
10
11
12
13
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 POUDRE VALLEY HOSPITAL
1024 S LEMAY
FORT COLLINS,CO80524
X X   X   X X   PHARMACY, LAB, CARDIOVASCULAR  
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
POUDRE VALLEY HEALTH CARE
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):
1
Yes No
Community Health Needs Assessment
1 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?.......................... 1   No
2 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............... 2   No
3 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...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
5 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 ................. 5 Yes  
6a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b 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. ............................. 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 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. ..............
8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 12
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): SEE PART V, SECTION C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b   No
11 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   No
b If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" to 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) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

POUDRE VALLEY HEALTH CARE
Name of hospital facility or letter of facility reporting group  
Financial Assistance Policy (FAP) Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 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):
a
b
c
d
e
16 Included measures to publicize the policy within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
h
i
Billing and Collections
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?.................................. 17 Yes  
18 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:
a
b
c
d
e
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

POUDRE VALLEY HEALTH CARE
Name of hospital facility or letter of facility reporting group  
Financial Assistance Policy (FAP) Yes No
19 Did the hospital facility or other authorized third 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?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 18. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 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?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 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? ............................... 23   No
If "Yes," explain in Section C.
24 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? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 3J: THE CHNA REPORT ALSO DESCRIBES CLINICAL SERVICES PROVIDED BY HOSPITAL FACILITY ADDRESSING THE FOUR LEADING CAUSES OF MORTALITY IN THE COUNTY.
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5: TWO COMMUNITY MEETINGS WERE HELD DURING FEBRUARY 2013 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. THE FOLLOWING INDIVIDUALS WERE CONSULTED:ANNETTE ALFANO, UNIVERSITY OF COLORADO HEALTHMARY ATCHISON, KAISER PERMANENTEKRISTIN BIERI, FOOD BANK FOR LARIMER COUNTYDEBORAH CAMPBELL, LARIMER COUNTY COMPASSJENNIFER CHASE, NORTHERN COLORADO AIDS PROJECTANDREA CLEMENT-JOHNSON, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTBRUCE COOPER, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYLORI DAIGLE, NORTHERN COLORADO AIDS PROJECTALISON DAWSON, DISABLED RESOURCE SERVICESEMILY DAWSON PETERSEN, TOUCHSTONE HEALTH PARTNERSTOM DONNELLY, LARIMER COUNTY COMMISSIONERSMICHELE DOYLE, COLUMBINE HEALTH CARE SYSTEMSLINDA FELLION, EARLY CHILDHOOD COUNCIL OF LARIMER COUNTYLEW GAITER, LARIMER COUNTY COMMISSIONERSCHAZZ GLAZE, SALUD FAMILY HEALTH CENTERNEIL GLUCKMAN, LARIMER COUNTY, ASSISTANT COUNTY MANAGERMARTHA HARGRAVES, COMMUNITY MEMBERBARBARA HARTMAN, THOMPSON SCHOOL DISTRICTSUE HEWITT, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYJESSICA HINTERBERG, CANDO WITH UNIVERSITY OF COLORADO HEALTHERICA IVERSON, FOOD BANK FOR LARIMER COUNTYSTEVE JOHNSON, LARIMER COUNTY COMMISSIONERSASHLEY KASPRZAK, TEAM FORT COLLINSKATY KOHNEN, LEAGUE OF WOMEN VOTERSJENNY LANGNESS, ALPHA CENTERJENNIFER LEE, LARIMER COUNTY BOARD OF HEALTHDIANA LINDEN, PLANNED PARENTHOOD OF THE ROCKY MOUNTAIN'S RESPONSIBLE SEX EDUCATION INSTITUTEMARIE MACPHERSON, LARIMER COUNTY DEPT OF HEALTH AND ENVIRONMENTJOHN MCGEE, CROSSROADS SAFEHOUSEDAWN NANNINI, TEAM FORT COLLINSKAREN NICHOLSON, ESTES PARK MEDICAL CENTERTRACI ODDY, BANNER MCKEE MEDICAL CENTERCAROL PLOCK, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYMARK RICHARDS, LARIMER COUNTY BOARD OF HEALTHDOUG RYAN, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTKIM SHARPE, HEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYBILL STOUT, WOMEN'S RESOURCE CENTERAVERIL STRAND, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTDEIRDRE SULLIVAN, CANDO WITH UNIVERSITY OF COLORADO HEALTHJILL TAYLOR, UNIVERSITY OF COLORADO HEALTHGRACE TAYLOR, UNIVERSITY OF COLORADO HEALTHMARILYN THAYER, COMMUNITY ORGANIZING TO REACH EMPOWERMENT (CORE) CENTERLEE THIELEN, THIELEN CONSULTINGCOLETTE THOMPSON, UNIVERSITY OF COLORADO HEALTHJANE VISTE, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTSCOTT VON BARGEN, TURNING POINT CENTER FOR YOUTH & FAMILY DEVELOPMENTMARGARET WATSON, UNITED WAY 2-1-1 OF LARIMER COUNTYNANCY WEBER, POUDRE SCHOOL DISTRICTVALERIE WENDELL, BOHEMIAN FOUNDATIONLISE YOUNGBLADE, HUMAN DEVELOPMENT AND FAMILY STUDIES/COLORADO STATE UNIVERSITYSTEVE YURASH, LARIMER COUNTY BOARD OF HEALTH
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6A: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2012 CHNA.
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6B: ALPHA CENTERBOHEMIAN FOUNDATIONCOLUMBINE HEALTH CARE SYSTEMSCOMMUNITY ORGANIZING TO REACH EMPOWERMENT CENTERCROSSROADS SAFEHOUSEDISABLES RESOURCE SERVICESEARLY CHILDHOOD COUNCIL OF LARIMER COUNTYFOOD BANK FOR LARIMER COUNTYHEALTH DISTRICT OF N. LARIMER COUNTYHEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYHUMAN DEVELOMENT AND FAMILY STUDIES @ CSUKAISER PERMANENTELARIMER COUNTRY DEPARTMENT OF HEALTH AND ENVIRONMENTLARIMER COUNTYLARIMER COUNTY BOARD OF HEALTHLARIMER COUNTY COMMISSIONERSLARIMER COUNTY COMPASSLEAGUE OF WOMEN VOTERSNORTHERN COLORADO AIDS PROJECTPLANNED PARENTHOODPOUDRE SCHOOL DISTRICTSALUD FAMILY HEALTH CENTERTEAM FORT COLLINSTHIELEN CONSULTINGTHOMPSON SCHOOL DISTRICTTOUCHSTONE HEALTH PARTNERSTURNING POINT CENTER FOR YOUTH AND FAMILY DEVELOPMENTUNITED WAY OF LARIMER COUNTYWOMEN'S RESOURCE CENTERPART V, LINE 7A:WEBSITE: HTTPS://WWW.UCHEALTH.ORG/DOCUMENTS/FILE-PDF/ABOUT- CHNA-WEB201213.PDFPART V, LINE 10A: HTTPS://WWW.UCHEALTH.ORG/DOCUMENTS/FILE-PDF /ABOUT-2013-IMPLEMENTATIONSTRATEGY-UCHEALTHNORTH.PDF
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 11: AN IDENTIFIED HEALTH ISSUE RELATED TO A HIGH RATE OF UNINTENDED TEEN PREGNANCY IN WELD COUNTY IS NOT BEING ADDRESSED WITH DIRECT RESOURCES ALLOCATED FROM POUDRE VALLEY HOSPITAL OR THE MEDICAL CENTER OF THE ROCKIES. THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT PROVIDES REPRODUCTIVE HEALTH SERVICES FOR TEENS THROUGH A TITLE X CLINIC. ADDITIONAL EDUCATION AND OUTREACH TO WELD COUNTY TEENS IS PROVIDED BY A COMMUNITY ORGANIZATION; LUTHERAN FAMILY SERVICES. POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDED SUPPORT TO THIS ORGANIZATION THROUGH CASH DONATIONS TOTALING $2,460.00 DURING THE 2012/13 FISCAL YEAR AND $2,500 DURING THE 2013/14 FISCAL YEAR. ANOTHER IDENTIFIED HEALTH ISSUE - MOTOR VEHICLE SAFETY FOR TEENS IN WELD COUNTY - IS ALSO NOT BEING DIRECTLY ADDRESSED DUE TO LACK OF RESOURCES. THE ISSUE IS BEING ADDRESSED BY A NON-PROFIT COMMUNITY COALITION - DRIVE SMART WELD COUNTY - WHICH HAS DEDICATED RESOURCES AND ACTION PLANS TO ADDRESS THIS ISSUE.PART V, LINE 16:FINANCIAL ASSISTANCE POLICY: HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4
PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16A WEBSITE: SEE PART V, SECTION C
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16B WEBSITE: SEE PART V, SECTION C
POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16C WEBSITE: SEE PART V, SECTION C
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
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?56
Name and address Type of Facility (describe)
1 HARMONY CAMPUS MOB
2121 E HARMONY RD
FORT COLLINS,CO80528
PHYSICIAN OFFICES, ONCOLOGY, HCOR, CANCER CENTER
2 HARMONY CAMPUS AMBULATORY CARE CENTER
2127 E HARMONY RD
FORT COLLINS,CO80528
SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE
3 MCR NORTH MOB
2500 ROCKY MTN AVE
LOVELAND,CO80538
PHYSICIAN OFFICES
4 CHMG CLINICS
1400 E BOULDER STREET
COLORADO SPRINGS,CO80909
PHYSICIAN OFFICES
5 GREELEY MEDICAL CLINIC
1900 16TH STREET
GREELEY,CO80631
PHYSICIAN OFFICES,LAB, RADIOLOGY & ONCOLOGY
6 REDSTONE
2315 E HARMONY RD
FORT COLLINS,CO80528
OUTPAITENT LAB, PHYSICIAN OFFICE, UROLOGY
7 CHMG-LONGMONT
1925 MOUNTAIN VIEW AVE
LONGMONT,CO80501
PHYSICIAN OFFICES
8 PHYSICIAN CLINICS
4110 BRIARGATE PARKWAY
COLORADO SPRINGS,CO80920
PHYSICIAN OFFICES
9 PEAKVIEW MEDICAL CENTER
5881 W 16TH STREET
GREELEY,CO80634
PHYSICIAN OFFICES, LAB & RADIOLOGY
10 PENNOCK PLACE
1025 PENNOCK PLACE
FORT COLLINS,CO80524
PHYSICIAN OFFICES, BLOOD BANK
11 MOUNTAIN CREST BEHAVIORAL HEALTH
4601 CORBETT DR
FORT COLLINS,CO80528
BEHAVORIAL HEALTH
12 PROSPECT MEDICAL PLAZA
1106 E PROSPECT SUITE 100
FORT COLLINS,CO80524
PHYSICIAN OFFICES, OUTPAITENT REHAB, NEUROLOGY, INT MEDICINE
13 CENTRE AVE HEALTH AND REHAB-JV
915 CENTRE AVE
FORT COLLINS,CO80526
REHAB
14 SNOW MESA
4674 SNOW MESA DRIVE
FORT COLLINS,CO80528
PHYSICIAN OFFICES
15 CHMG CHEYENNE MEDICAL SPECIALISTS
5050 POWDERHOUSE RD
CHEYENNE,WY82009
PHYSICIAN OFFICES
16 WESTBRIDGE
1107 S LEMAY
FORT COLLINS,CO80524
PHYSICIAN OFFICES, BLOOD DRAW, SLEEP LAB, WEE STEPS
17 CHMG PHYSICIAN CLINICS
525 N FOOTE AVE SUITE 302
COLORADO SPRINGS,CO80910
PHYSICIAN OFFICES
18 SURGERY CENTER OF FT COLLINS-JV
1100 E PROSPECT RD
FORT COLLINS,CO80524
SURGERY CENTER
19 MCR SOUTH MOB
2500 ROCKY MTN AVE
LOVELAND,CO80538
PHYSICIAN OFFICES, HCOR, SSOR, SLEEP LAB, SURGERY CENTER
20 WINDSOR MEDICAL CENTER
1455 MAIN STREET
WINDSOR,CO80550
PHYSICIAN OFFICES, RADIOLOGY, LAB
21 MEMORIAL NEUROSCIENCES
1725 BOULDER STREET SUITE 101
COLORADO SPRINGS,CO80909
PHYSICIAN OFFICES
22 UROLOGY CENTER OF THE ROCKIES
3520 E 15TH STREET
LOVELAND,CO80538
PHYSICIAN OFFICES
23 EXPRESS LAB
1020 DOCTORS LANE
FORT COLLINS,CO80524
LAB
24 CHMG OB-GYN CLINIC
1715 61ST AVENUE
GREELEY,CO80631
PHYSICIAN OFFICES
25 NORTH SPRINGS FAMILY MEDICINE & URGENT C
8540 SCARBOROUGH DRIVE
COLORADO SPRINGS,CO80920
PHYSICIAN OFFICES
26 CHILDREN'S THERAPY
1500 S LEMAY
FORT COLLINS,CO80526
THERAPY
27 WEST LOVELAND
3850 N GRANT AVE
LOVELAND,CO80538
URGENT CARE, PHYSICIAN OFFICES
28 TIMBERLINE MEDICAL
131 STANLEY DR
ESTES PARK,CO80517
PHYSICIAN OFFICES
29 CHMG PRIMARY CARE AT BRIARGATE
8890 N UNION BLVD SUITE 100B
COLORADO SPRINGS,CO80920
PHYSICIAN OFFICES
30 PHYSICIAN CLINICS
175 S UNION BLVD
COLORADO SPRINGS,CO80910
PHYSICIAN OFFICES
31 COLUMBINE POUDRE HOMECARE-JV
915 CENTRE AVE
FORT COLLINS,CO80526
HOME HEALTHCARE
32 HCORSCOTTSBLUFF
2 W 42ND ST 2200
SCOTTSBLUFF,NE69361
PHYSICIAN OFFICES
33 CHMG PRIMARY CARE - ROCKRIMMON
6615 DELMONICO DRIVE
COLORADO SPRINGS,CO80919
PHYSICIAN OFFICES
34 MEMORIAL SUNFLOWER FAMILY MEDICINE
1730 N CORONA STREET
COLORADO SPRINGS,CO80907
PHYSICIAN OFFICES
35 PRIMARY CARE-STERLING
620 IRIS DRIVE
STERLING,CO80751
PHYSICIAN OFFICES
36 EYE LASER CENTER OF N COLORADO-JV
1725 EAST PROSPECT RD
FORT COLLINS,CO80525
PHYSICIAN OFFICES
37 CHMG-FIRESTONE
660 FIRESTONE BLVD
FIRESTONE,CO80504
PHYSICIAN OFFICES
38 THOMPSON VALLEY TOWNE CENTER
1327 EAGLE DRIVE
LOVELAND,CO80537
PHYSICIAN OFFICES
39 ORTHOPEDIC & HAND
3830 N GRANT AVE
LOVELAND,CO80538
PHYSICIAN OFFICES
40 YAMPA VALLEY STEAMBOAT
940 CENTRAL PARK DR 290
STEAMBOAT SPRINGS,CO80487
PHYSICIAN OFFICES
41 THE VEIN AND LASER CENTER-JV
2008 CARIBOU DRIVE
FORT COLLINS,CO80525
PHYSICIAN OFFICES
42 CHMG PRIMARY CARE - NO UNION
5333 N UNION BLVD SUITE 200
COLORADO SPRINGS,CO80918
PHYSICIAN OFFICES
43 FORT MORGAN
1000 LINCOLN STREET 207
FORT MORGAN,CO80701
PHYSICIAN OFFICES
44 WATER VALLEY
1870 MARINA PLAZA DRIVE
WINDSOR,CO80550
OUTPATIENT REHAB
45 LARAMIE
3116 WILLET DRIVE
LARAMIE,WY82070
PHYSICIAN OFFICES
46 ESTES PARK
555 PROSPECT AVE
ESTES PARK,CO80517
PHYSICIAN OFFICES
47 CRAIG
595 RUSSELL STREET
CRAIG,CO81625
PHYSICIAN OFFICES
48 SIDNEY
1625 DORWART DRIVE
SIDNEY,NE69162
PHYSICIAN OFFICES
49 CHMG HCOR CV SURGEON
2030 MOUNTAIN VIEW AVE 540
LONGMONT,CO80501
PHYSICIAN OFFICES
50 PHLEBOTOMY STATION
1107 SOUTH LEMAY AVE
FORT COLLINS,CO80526
LAB DRAWS
51 PHLEBOTOMY STATION
1113 OAKRIDGE DRIVE
FORT COLLINS,CO80525
LAB DRAWS
52 PHLEBOTOMY STATION
2001 S SHIELDS
FORT COLLINS,CO80526
LAB DRAWS
53 PHLEBOTOMY STATION
2025 BIG HORN DRIVE
FORT COLLINS,CO80525
LAB DRAWS
54 PHLEBOTOMY STATION
3519 RICHMOND DRIVE
FORT COLLINS,CO80526
LAB DRAWS
55 HAYTHORN BROTHERS
7251 W 20TH ST
GREELEY,CO80631
SLEEP LAB
56 PRIMARY CARE-MONUMENT
15854 JACKSON CREEK PARKWAY SUITE
120
MONUMENT,CO80132
PHYSICIAN OFFICES
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
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 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS.
PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING.
PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $23,781,564.
PART II, COMMUNITY BUILDING ACTIVITIES: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES.
PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 87,131,659CENTER AVE COST REPORT: 3,678,552COLUMBINE HOMECARE COST REPORT: 1,200,461PVHC DISALLOWED PROGRAMS: 800,587JOINT VENTURES: 45,048,852TOTAL TO LINE 5: 137,860,111PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2015 COST REPORT AGGREGATED WITH DISREGARDED ENTITIES AND OWNERSHIP PORTIONS OF JOINT VENTURES. PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: 106,716,188CENTRE AVE COST REPORT: 5,645,512COLUMBINE HOMECARE COST REPORT: 1,436,645PVHC DISALLOWED PROGRAMS: 1,089,938JOINT VENTURES: 62,085,954TOTAL TO LINE 6: 176,974,237
PART III, LINE 8: APPROXIMATELY 23.48% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION.
PART III, LINE 9B: PATIENT PROVIDES DOCUMENTATION BASED ON COLORADO INDIGENT CARE GUIDELINES, REVIEWED BY FINANCIAL ASSISTANCE COMMITTEE (FAC), CROSS FUNCTIONAL TEAM CHAIRED BY DIRECTOR PATIENT FINANCIAL SERVICES. UPON APPROVAL OR DENIAL OF THE REQUEST FOR CHARITABLE AID FROM THE FAC, THE PATIENT WILL BE ADVISED OF THE DECISION. THE BILL IS PARTIALLY OR TOTALLY ADJUSTED AS APPROVED BY THE FAC, NO FURTHER COLLECTION PROCESS WITH THE PATIENT. FOR ANY PORTION NOT ADJUSTED OFF, THE PROPER SEQUENCE OF ATTEMPTS TO COLLECT ARE FOLLOWED. FINAL ASSIGNMENT OF THE BILL IS TO A COLLECTION AGENCY.
PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS).
PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE EMERGENCY DEPARTMENT, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE.
PART VI, LINE 4: POUDRE VALLEY HEALTH CARE INC. IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTH CARE TO HEALTH. BASED IN NORTHERN COLORADO, PVHC PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVHC IS A PART OF THE UNIVERSITY OF COLORADO HEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, COLORADO HEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS AS FOLLOWS: WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES.
PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS . WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED.
PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING.
PART VI, LINE 7, REPORTS FILED WITH STATES CO
Schedule H (Form 990) 2014
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