Community Benefit Insight - Tax-exempt hospital

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Community Hospital Inc

Grape Community Hospital - Hamburg

275 Hwy North
Hamburg, IA 51640

Bed count	25	Medicare provider number	161324	Member of the Council of Teaching Hospitals	NO	Children's hospital	NO

EIN: 420738969

Display data for year:

Community Benefit Spending- 2021
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)

7.06%

Spending by Community Benefit Category- 2021
(as % of total functional expenses)

* = CBI denoted preventative categories

Community Benefit Spending Compared to Functional Expenses, 2010-2021

Additional data

Community Benefit Expenditures: 2021

All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Amount spent in the following IRS community benefit categories:

Financial Assistance at cost as % of operating expenses	$ 36,972 0.26 %
Medicaid as % of operating expenses	$ 873,509 6.11 %
Costs of other means-tested government programs as % of operating expenses	$ 0 0 %
Health professions education as % of operating expenses	$ 0 0 %
Subsidized health services as % of operating expenses	$ 97,388 0.68 %
Research as % of operating expenses	$ 0 0 %
Community health improvement services and community benefit operations* as % of operating expenses Note: these two community benefit categories are reported together on the Schedule H, part I, line 7e.	$ 2,281 0.02 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 0 0 %
Community building* as % of operating expenses	$ 0 0 %

* = CBI denoted preventative categories

Community building activities details:

Did tax-exempt hospital report community building activities?	Not available
Number of activities or programs (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Persons served (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Community building expense as % of operating expenses	$ 0 0 %
Physical improvements and housing as % of community building expenses	$ 0
Economic development as % of community building expenses	$ 0
Community support as % of community building expenses	$ 0
Environmental improvements as % of community building expenses	$ 0
Leadership development and training for community members as % of community building expenses	$ 0
Coalition building as % of community building expenses	$ 0
Community health improvement advocacy as % of community building expenses	$ 0
Workforce development as % of community building expenses	$ 0
Other as % of community building expenses	$ 0
Direct offsetting revenue	$ 0
Physical improvements and housing	$ 0
Economic development	$ 0
Community support	$ 0
Environmental improvements	$ 0
Leadership development and training for community members	$ 0
Coalition building	$ 0
Community health improvement advocacy	$ 0
Workforce development	$ 0
Other	$ 0

Other Useful Tax-exempt Hospital Information: 2021

In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.

Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt as % of operating expenses	$ 387,704 2.71 %
Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program?	NO

Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2022 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.

Does the organization have a written financial assistance (charity care) policy?	YES
Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients?	YES
Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy as % of operating expenses	$ 0 0 %

Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.

Community Health Needs Assessment Activities: 2021

The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.

Did the tax-exempt hospital report that they had conducted a CHNA?	YES
Did the CHNA define the community served by the tax-exempt hospital?	YES
Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital?	YES
Did the tax-exempt hospital make the CHNA widely available (i.e. post online)?	YES
Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA?	YES

Supplemental Information: 2021

This section presents qualitative information submitted by the hospital, verbatim from the 990H record.

Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.

4A (Expenses $ 11886820 including grants of $ 0) (Revenue $ 11988401)
GEORGE C. GRAPE COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL THAT RECEIVED INITIAL CERTIFICATION ON AUGUST 1, 2001. THE HOSPITAL IS OWNED AND OPERATED BY COMMUNITY HOSPITAL INC., DOING BUSINESS AS GEORGE C. GRAPE COMMUNITY HOSPITAL.AS A CRITICAL ACCESS HOSPITAL, GEORGE C. GRAPE COMMUNITY HOSPITAL PERFORMS AN ANNUAL PROGRAM EVALUATION IN ORDER TO DETERMINE WHETHER THE SERVICE IS APPROPRIATE, ADEQUATE, EFFECTIVE AND EFFICIENT. THIS EVALUATION ALSO DETERMINES WHETHER THE UTILIZATION OF SERVICES WAS APPROPRIATE, ESTABLISHED POLICIES WERE FOLLOWED, DETERMINES ANY CHANGES NEEDED AND RECOMMENDS PROJECTS FOR DEVELOPMENT DURING THE NEXT YEAR. STATISTICAL ANALYSIS: 1.) ACUTE CARE- THERE WERE A TOTAL OF 63 INPATIENT ADMISSIONS DURING FISCAL YEAR 2022 COMPARED TO 64 ADMISSIONS DURING FISCAL YEAR 2021.2.) SWING BED- 34 SWING BED ADMISSIONS WERE RECORDED DURING FISCAL YEAR 2022 COMPARED TO 40 ADMISSIONS DURING FISCAL YEAR 2021. 3.) SURGICAL CASES- THERE WERE A TOTAL OF 194 SURGICAL CASES FOR THE 2022 FISCAL YEAR AS COMPARED TO 186 SURGICAL CASES DURING FISCAL YEAR 2021.4.) OUTPATIENT SERVICES- EMERGENCY ROOM SERVICES DECREASED FROM 986 VISITS IN FISCAL YEAR 2021 TO 898 VISITS IN FISCAL YEAR 2022. LABORATORY SERVICES INCREASED FROM 11,947 IN FISCAL YEAR 2021 TO 12,181 IN FISCAL YEAR 2022. RADIOLOGY SERVICES DECREASED FROM 2,268 IN FISCAL YEAR 2021 TO 2,099 IN FISCAL YEAR 2022. ULTRASOUND SERVICES DECREASED FROM 612 IN FISCAL YEAR 2021 TO 544 IN FISCAL YEAR 2022. NUCLEAR MEDICINE SERVICES DECREASED FROM 61 IN FISCAL YEAR 2021 TO 39 IN FISCAL YEAR 2022.

Facility Information

Schedule H (Form 990) Section C. Supplemental Information for Part V, Section B.

GEORGE C. GRAPE COMMUNITY HOSPITAL
PART V, SECTION B, LINE 5: IN ORDER TO REPRESENT THE COMMUNITY EQUALLY, MULTIPLE AVENUES OF COLLECTING INFORMATION WERE USED THAT PROVIDED NECESSARY INFORMATION TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY.AVENUES IDENTIFIED:-FOCUS GROUP (TOWN HALL MEETING)-SURVEY-STATE AND COUNTY HEALTH STATISTICSTO DETERMINE THE MAIN HEALTH CONCERNS OF THE COMMUNITY THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT COMMITTEE INVITED MEMBERS OF THE COMMUNITY TO BE PART OF A TOWN HALL MEETING. THE COMMUNITY MEMBER MEETING CONSISTED OF PEOPLE FROM THE VARIOUS HEALTH CARE AREAS SUCH AS SCHOOL NURSE, OCCUPATIONAL THERAPIST, PHARMACIST, CASE MANAGER FOR MI/MR, IOWA STATE UNIVERSITY EXTENSION OUTREACH, MEDICAL CLINICS, A MEMBER FROM THE HOSPITAL'S BOARD OF DIRECTORS AND MEMBERS OF THE BUSINESS COMMUNITY.THERE WAS AN ONLINE SURVEY CONDUCTED. ADVERTISEMENTS FOR THE SURVEY WERE PUT IN THE HOSPITAL'S NEWSLETTER AND MAILED OUT TO THE COMMUNITY. THE COMMUNITY WAS ENCOURAGED TO GO ONLINE AND FILL OUT THE SURVEY.THE HOSPITAL'S COMMUNITY NEEDS ASSESSMENT COMMITTEE MET AND REVIEWED THE SURVEYS. THE INFORMATION AND DATA FROM THE SURVEY WERE THEN PRESENTED TO THE TOWN HALL MEETING GROUP, ALONG WITH THE PROPOSED ACTION TO BE TAKEN BY THE HOSPITAL.

GEORGE C. GRAPE COMMUNITY HOSPITAL
"PART V, SECTION B, LINE 11: IN THE 2021-2022 FISCAL YEAR, GEORGE C. GRAPE COMMUNITY HOSPITAL (THE HOSPITAL) CONTINUED TO ADDRESS THE NEEDS OF THE COMMUNITY (AS IDENTIFIED IN THE CURRENT COMMUNITY HEALTH NEEDS ASSESSMENT REPORT).SPECIFIC NEEDS TO BE ADDRESSED INCLUDE MENTAL HEALTH, PRIMARY CARE, FOOD INSECURITY, VISITING SPECIALISTS, SENIOR ACTIVITIES, ADEQUATE HEALTHCARE STAFFING AND SUBSTANCE ABUSE.IN OCTOBER 2021, A FACEBOOK POST WAS PUBLISHED FOR THE FLU CLINIC SCHEDULE. THIS POST ALSO INCLUDED INFORMATION ON THE BENEFITS OF GETTING A FLU VACCINATION.IN OCTOBER 2021, A FACEBOOK POST WAS PUBLISHED FOR THE COVID-19 BOOSTER SHOTS. THIS POST ALSO INCLUDED INFORMATION ON THE BENEFITS OF THE COVID-19 VACCINATION.IN OCTOBER 2021, THE HOSPITAL ATTENDED THE MARINE SIMONS ELEMENTARY AND MIDDLE SCHOOL TRICK OR TRUNK. GOODIES AND AN ACTIVITY PACKET WAS PROVIDED TO THOSE IN ATTENDANCE. SOME OF THE ACTIVITIES IN THE PACKET INCLUDED HEALTHY SNACK OPTIONS, HALLOWEEN THEMED EXERCISES AND HOW TO STAY SAFE WHILE TRICK OR TREATING. ALSO, THE HOSPITAL ATTENDED THE KIWANIS HALLOWEEN BASH. GOODIES AND AN ACTIVITY PACKET WAS PROVIDED TO THOSE IN ATTENDANCE.IN JANUARY 2022, A FACEBOOK POST WAS PUBLISHED FOR THE BLOOD DRIVE HOSTED BY THE HOSPITAL. THIS POST ALSO INCLUDED INFORMATION ON DONATING BLOOD.IN FEBRUARY 2022, A FACEBOOK POST WAS PUBLISHED ABOUT MIDWEST MENTAL HEALTH. MIDWEST MENTAL HEALTH PROVIDES SERVICES FOR FAMILY THERAPY, MARRIAGE COUNSELING, MEDICATION MANAGEMENT, INDIVIDUAL THERAPY, PLAY THERAPY, AND BHIS.IN MARCH 2022, A FACEBOOK POST WAS PUBLISHED ABOUT A REPORT FROM THE IOWA COLLEGE OF PUBLIC HEALTH ABOUT CANCER IN IOWA. IT GAVE FACTS LIKE ""IT IS ESTIMATED IN 2021 THERE WOULD BE 1,600 DIAGNOSED CASES OF COLON AND RECTUM CANCERS IN JUST THE STATE OF IOWA. THE CDC RECOMMENDS SCREENING BY THE AGE OF 45 UNLESS YOU ARE CONSIDERED TO BE AT RISK.""IN MARCH 2022, A FACEBOOK POST WAS PUBLISHED ON THE BENEFITS OF MORE SUNLIGHT.IN APRIL 2022, A FACEBOOK POST WAS PUBLISHED ON INFORMATION ON BECOMING AN ORGAN DONOR. THIS POST ALSO INCLUDED A LINK TO INFORMATION ABOUT ORGAN DONATION AND THE SIGN UP TO BE AN ORGAN DONOR.IN APRIL 2022, THE HOSPITAL HOSTED AN EASTER EGG HUNT. AT THIS EVENT THERE WERE FUN ACTIVITIES PROVIDED FOR THE KIDS. THESE ACTIVITIES INCLUDED A BUNNY HOP RACE, EGG ON THE SPOON RACE, AND EAT THIS NOT THAT ACTIVITY. HOT DOGS WERE PROVIDED AFTERWARDS.IN MAY 2022, A FACEBOOK POST WAS PUBLISHED FOR RED NOSE DAY. RED NOSE DAY IS A PROGRAM TO ENSURE CHILDREN HAVE ACCESS TO HEALTHCARE, EDUCATION, FOOD, AND ARE SAFE AND HAVE THE OPPORTUNITY TO THRIVE. THIS POST INCLUDED A LINK TO THE RED NOSE DAY WEBSITE FOR MORE INFORMATION.IN MAY 2022, THE HOSPITAL SPONSORED RIDE FOR RESILIENCY. THIS IS HOSTED BY THE NATIONAL ALLIANCE ON MENTAL ILLNESS. THIS EVENT IS FOR PEOPLE TO LEARN MORE ON MENTAL HEALTH.IN JUNE 2022, EMPLOYEES OF THE HOSPITAL VOLUNTEERED AT NO HUNGER SUMMER. THIS PROGRAM IS TO OFFER FREE LUNCH MEALS TO ALL CHILDREN IN THE COUNTY.IN JULY 2022, A FACEBOOK POST WAS PUBLISHED ABOUT SEAT BELT SAFETY. THIS POST INCLUDED A LINK TO NHTSA THAT GAVE MORE INFORMATION.IN AUGUST 2022, THE HOSPITAL HOSTED A SCHOOL DRIVE FOR THE LOCAL SCHOOL.THE NEEDS NOT ADDRESSED IN THE CURRENT YEAR INCLUDE THE FOLLOWING:APPROACH THE LOCAL SCHOOL FOR JOINT DEVELOPMENT OF A WALKING TRAIL: THIS WAS NOT ADDRESSED DUE TO FINANCIAL UNFEASIBILITY FOR BOTH PARTIES. GRANTS WERE NOT AVAILABLE.CREATE/PROMOTE AWARENESS OF AVAILABLE TRANSPORTATION SERVICES: THIS WAS NOT ADDRESSED DUE TO THE COLLECTION OF TRANSPORTATION OPPORTUNITIES BEING INCOMPLETE AND AN AWARENESS CAMPAIGN WAS NOT INITIATED. SWITA OPPORTUNITIES WERE NOT FULLY INVESTIGATED, AND LOCAL CHARITY GROUPS THAT OFFER SERVICES WERE NOT AVAILABLE DUE TO COVID.LACK OF DENTAL SERVICES/INSURANCE: WE CONTINUE TO WORK WITH TOWN COUNCIL FOR GRANT RESEARCH, FOLLOWING WITH DELTA DENTAL. FOLLOWING UP WITH THE TOWN COUNCILS TO ENSURE THAT ACTION ITEMS ARE BEING IMPLEMENTED. TIE INTO FLUORIDE INITIATIVE: THIS WAS NOT ADDRESSED DUE TO NOT BEING ABLE TO APPROACH THE TOWN COUNCIL AS WE HOPED."

GEORGE C. GRAPE COMMUNITY HOSPITAL
PART V, SECTION B, LINE 20E: WE ORALLY NOTIFY PATIENTS WHEN THEY COME IN DURING THE FINANCIAL COUNSELORS WORKING HOURS. A PLAIN LANGUAGE SUMMARY OF THE FAP IS MAILED TO EVERYONE 30 DAYS PRIOR TO THEIR ACCOUNT BEING SENT TO COLLECTIONS.

Supplemental Information

Schedule H (Form 990) Part VI

PART I, LINE 3C:
FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS.

PART I, LINE 6A:
THE COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED PARTY.

PART I, LINE 7:
THE COST TO CHARGE RATIO WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST AS DERIVED FROM COMMUNITY HOSPITAL, INC.'S INTERNAL ACCOUNTING RECORDS.

PART I, LINE 7G:
THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G.

PART I, LN 7 COL(F):
THE IMPLICIT PRICE CONCESSIONS INCLUDED ON FORM 990, PART XI, LINE 25, COLUMN (A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $387,704.

PART II, COMMUNITY BUILDING ACTIVITIES:
THE HOSPITAL, ALONG WITH A FEW OTHER SPONSORS IN THE COMMUNITY, PUT TOGETHER A HALLOWEEN EVENT THAT PROVIDED AN EVENING OF FOOD, FUN AND SAFETY FOR THE CHILDREN OF OUR COMMUNITY AND SURROUNDING COMMUNITIES. THIS EVENT ALLOWED CHILDREN TO HAVE A MEAL AND HEALTH PROMOTING MATERIALS. IT ALSO KICKS OFF CHILDREN GOING AROUND TO NEIGHBORHOODS WHILE IT IS STILL DAYLIGHT WHICH ALLOWS IT TO BE SAFER FOR THE CHILDREN AS THEY ARE HOME EARLIER.

PART III, LINE 2:
THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS.

PART III, LINE 3:
THE HOSPITAL PROVIDES PATIENT FINANCIAL ASSISTANCE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS POLICY OF THE HOSPITAL NOT TO PURSE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING PATIENT FINANCIAL ASSISTANCE BY AGGREGATING THE DIRECT AND INDIRECT COST, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON THE OVERALL COST TO CHARGE RATIO FOR THE HOSPITAL. THE COSTS OF CARING FOR PATIENTS WHO QUALIFY UNDER THE HOSPITAL'S PATIENT FINANCIAL ASSISTANCE POLICY FOR THE YEARS ENDED SEPTEMBER 30, 2022 AND 2021 WERE APPROXIMATELY $34,000 AND 62,000, RESPECTIVELY.

PART III, LINE 4:
"THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED ""PATIENT RECEIVABLES"", ""PATIENT SERVICE REVENUE AND ""PATIENT FINANCIAL ASSISTANCE""."

PART III, LINE 8:
"""MEDICARE ALLOWABLE COSTS OF CARE"" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT, D, E, H AND M WORKSHEETS, OR PS&R. ALL OF THE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT."

PART III, LINE 9B:
THE COLLECTIONS/CHARITY WRITE-OFF POLICY PROVIDES THAT ONCE THE PATIENT/GUARANTOR QUALIFIES FOR CHARITY CARE HE/SHE WILL BE NOTIFIED OF THE AMOUNT OF FREE CARE AND THE NON-CHARITY AMOUNT. PAYMENT ARRANGEMENTS WILL BE MADE FOR THE NON-CHARITY AMOUNT AT THE TIME OF NOTIFICATION.

PART VI, LINE 2:
THE GEORGE C. GRAPE COMMUNITY HOSPITAL (GCGCH) MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED DURING FISCAL YEAR 2022. THE RESULTS WILL ASSIST GCGCH LEADERSHIP IN RESPONDING TO THE HEALTH NEEDS IDENTIFIED BY THE ANALYSIS.

PART VI, LINE 3:
THE HOSPITAL COMMUNICATES VIA MAIL WITH EACH MEDICARE PATIENT. THE ON STAFF FINANCIAL COUNSELOR ASSISTS PATIENTS IN COMPLETING THIS FORM WHEN NECESSARY. PATIENTS WILL RECEIVE STATEMENTS OF ACCOUNT VIA MAIL. WHEN NO PAYMENTS ARE RECEIVED BY THE 3RD MONTHLY STATEMENT, FINANCIAL ASSISTANCE POLICY INFORMATION IS INCLUDED IN THE MAILING. WHEN POSSIBLE, THE FINANCIAL COUNSELOR WILL SPEAK WITH PATIENTS PERSONALLY BEFORE BEING DISCHARGED TO DISCUSS THEIR CHARITY CARE NEEDS.

PART VI, LINE 4:
OUR PRIMARY SERVICE AREA INCLUDES FREMONT COUNTY. THE NORTHERN PART OF THE COUNTY IS BEGINNING TO GROW AT A SLOW PACE. THE MIDDLE AND SOUTHERN PART OF THE COUNTY IS EITHER DECLINING OR MAINTAINING THEIR POPULATIONS. THE SOUTHERN PART OF THE COUNTY ALSO HAS A HIGH POVERTY RATE. THIS SERVICE AREA HAS A POPULATION OF 7,147. OUR SECONDARY SERVICE AREA INCLUDES THREE SURROUNDING COUNTIES IN IOWA, TWO IN MISSOURI, AND TWO IN NEBRASKA WHICH HAVE AN ESTIMATED POPULATION OF 93,000. THE HOSPITAL DOES SERVE SOME PATIENTS IN THE SECONDARY SERVICE AREA, BUT THE MAJORITY OF THE PATIENTS COME FROM THE PRIMARY SERVICE AREA.

PART VI, LINE 5:
THERE ARE NO OTHER ACTIVITIES THAT FURTHER THE PROMOTION OF THE HEALTH OF THE COMMUNITY.

PART VI, LINE 6:
COMMUNITY HOSPITAL, INC. IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION.

PART VI, LINE 7, REPORTS FILED WITH STATES
IA

Operating expenses	$ 14,307,239
Total amount spent on community benefits as % of operating expenses	$ 1,010,150 7.06 %