__Ul/U!J / 2015 15: 31! FAX Kansas Hospital Assoc 141001 KANSAS GOVERNMENTAL ETHICS COMMISSION ff~c RECEIPTS AND EXPENDITURES REPORT ~f!l'l2Q . OF A POLITICAL OR PARTY COMMlf8 ,. EE JA,fV o 0 ,, ~'n177.~h··1 <015 October 27, 2014 ' · _;,;:..t~ 1 • " G6 Co1r;, FILE WITH SECRETARY OF STATE rniss1011 SEE REVERSE SIDE FOR INSTRUCTIONS A. Name of Committee: Kansas Hospital AssociaUon Political Action Committee Address: 215 SE 8th Street City and Zip Code: r_ap_e_ka_, _ss_s_o1_________________________ _ This is a (check one): __ Party Committee X Political Committee B. Check only if appropriate: L Amended Filing __ Termination Report C. Summary {covering the period from July 2~, 2014 through October 23, 2014) $93,891.25 1. Cash on hand at beginning of period ......................................................................... 2. Total Contributions and Other Receipts (Use Schedule A) ....................................... $35,921.30 3. Cash available this period (Add Lines 1 and 2) ......................................................... $129,812.55 4. Total Expenditures and Other Disbursements (Use Schedule C) .............................. $56,073.51 5. Cash on hand at close of period (Subtract Line 4 from 3) .......................................... $73,739.04 6. In-Kind Contributions (Use Schedule B) ........ $2,469.84 7. Other Transactions (Use Schedule D) ............ .. $0.00 D. "I declare that this report, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belie is true, correct and com lete. I understand that the intentional failure to file this document or· entiona filing a · lass A mis errieanor." Date GEC Form Rev, 2014 Ul / UlJ / ZUlb 1!:>:;51! J:<"AA Kansas Hospital Assoc 141002 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan E funds ~ Receipt Randall Brown Chief of Medical Staff $100.00 117211th Rd Community Memorial Healthcare 07/30/2014 Marysville, KS 66508-8643 ./ Curtis Hawkinson Chief Executive Officer $280.00 1109 Keystone Rd. Community Memorial Healthcare 07/3012014 Marysville, KS 66508-1338 ./ Chad Austin Sr. Vice President, Government $76.92 6518 SW 26th Court Relations 07/30/2014 Topeka, KS 66614-4305 Kansas Hospital Association ./ Kevan Trenkle Chief Executive Officer $100.00 1473 Prairie Dr. Citizens Medical Center 08/08/2014 Colby, KS 67701-9303 Steven Perkins Chief Executive Officer $350.00 20 Crestwood Dr. South Central Kansas Medical 08/12/2014 Arkansas City, KS 67005-9005 Center Service Corporation Kansas Health $1,000.00 Kansas Hospital Association 08115/2014 Harold Courtois Chief Executive Officer $200.00 08/15/2014 PO Box 851 Russell Regional Hospital Russell, KS 67665-0851 Rosalind Lewis Chief Nursing Officer $200.00 08119/2014 13477 Curtiss Circle Commun,lty HealthCare System Onaga, KS 66521-9574 George Stover Chief Executive Officer $325.00 08/22/2014 1227 W. Noble St. Rice County District Hospital Lyons, KS 67554-3029 Steve Elmore $425.00 08/22/2014 1107 McArtar Rd. United Wireless Dodge City, KS 67801-6031 Trustee • $4,700.00 08122/2014 $7,756.92 Page _1__ of_1_1_ UL / Ul:l / ZULn Ln:il1S !''AA. Kansas Hospital Assoc !41003 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appr9prfate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan E funds 0th.;"" Receipt Joni Bergstrom OR Supervisor $150.00 Cloud County Health Center 08/22/2014 ./ John Hart Chief Executive Officer $150.00 309 N. 9th Sl Fredonia Regional Hospital 08/22/2014 Fredonia, KS 66736-1421 ./ Tracy Fanshier Trustee-Stafford Co. Hosp. $3,100.00 2010 N. US Hwy 281 08/22/2014 Great Bend, KS 67530-8712 ./ Joe Pedley Vice President and Chief Financial $100.00 5624 Villa Drive Officer 08/27/2014 Lawrence, KS 66047-8300 Lawrence Memorial Hospital ./ Kathleen Clausing-Willis Vice President/COO $100.00 1071 E 1400 Rd Lawrence Memorial Hospital 08/27/2014 Lawrence, KS 66046-9633 ./ Jane Maskus Vice President and Chief 5100.00 24215 W. 68th St. Information Officer 08/27/2014 Shawnee, KS 66226-3539 Lawrence Memorial Hospital ./ Eugene Meyer President and Chief Executive $500.00 08/27/2014 325 Maine Street Officer Lawrence, KS 66044-1360 Lawrence Memorial Hospital ./ Janice Early Hospital Employee $100.00 08/27/2014 902 Riverside Ct Lawrence Memorial Hospital Lawrence, KS 66044-4092 ./ Sheryle D'Amico VP $200,00 08/27/2014 737 N. 1550 Rd. Lawrence Memorial Hospital Lawrence, KS 66049-9198 ./ Joe Duerr Chief Executive Officer $250.00 08/29/2014 501 North 14th Street Morton County Health System Perry, OK 73077-5021 ./ Chief Executive Officer $200.00 08/29/2014 Rawlins County Health Center ./ $4,QSO.OO Page _2__ of-22._ 01/ 09 / 2015 15:39 FAX Kansas Hospital Assoc 141004 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan ~ Other Receipt Terry Pound Chief Financial Officer $150.00 420 S Pioneer Rice County District Hospital 08/29/2014 Lyons, KS 67554-2613 ./ George Stover Chief Executive Officer 5150.00 1227 W. Noble St. Rice County District Hospital 08/29/2014 Lyons, KS 67554-3029 ./ Randy Lindauer Chief Executive Officer $200.00 Coffey County Hospital 08/29/2014 ./ Tammy Peterman Executive Vice President, Chief $500.00 3901 Rainbow Blvd Operating Officer 08/29/2014 Kansas City, KS 66103-2937 - University of Kansas Hospital, The Kevin Hicks President end CEO $1 ,000.00 2316 East Meyer Boulevard Overland Park Regional Medical 09/04/2014 Kansas City, MO 64132-1136 Center Steven Wilkinson President and Chief Executive $1,500.00 5721 West 119th Street Officer 09/04/2014 Overland Park, KS 66209-3722 Menorah Medical Center ./ Hugh Tappan President and Chief Executive $2,500.00 09/0412014 14000 E. Castlewood Circle Officer Wichita, KS 67214-4910 Wesley Medical Center ./ Dennis Hachenberg Chief Executive Officer $500.00 09/04/2014 105 N. Oak St. Anderso~ County Hospital Garnett, KS 66032-0309 ./ Adele Ducharme Chief Executive Officer $500.00 09/04/2014 2218 NW 81st Ct Saint Luke's Cushing Hospital Kansas City, MO 64151-3700 ./ Jani Johnson President and Chief Executive $600.00 09/04/2014 7416 Mullen Rd Officer Shawnee, KS 66216-3777 Saint Luke's South Hospital ./ Sr. Vice President, Government $76.92 09/04/2014 Relations Kansas Hospital Association ./ {It~'"-, $7,676.92 Page _3__ of_1_1_ 01/ 09/ 2015 15:39 FAX Kansas Hospita~ Assoc 14!005 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Aclion Committee (Name of Party Committee or Political Committee) Occupation & Industry of . Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loso E fuods ~ Receipt Julie Ward Vice President of Patient Care $100.00 3215 Northwestern Avenue Services 09/05/2014 Hutchinson, KS 67502-1105 Hutchinson Regional Medical Center ./ Kevin Miller President and Chief Executive $100.00 69 Willowbrook Rd. Officer 09/05/2014 Hutchinson, KS 67502-8006 Hutchinson Regional Medical Center ./ Kendall E. Johnson $100.00 4403 Spyglass Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-5643 Center ./ Peggy R. Tuxhorn $100.00 2503 Rambler Rd. Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-5133 Center . ./ Jenice Schulte OR Manager $100.00 3811 Mission Dr. Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-8096 Center ./ Jeremy Taylor Director of Imaging $100.00 900 E. 36th Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-3001 Center ./ Elizabeth Peirce Board Mli'mber $100.00 09/05/2014 2813 Westminster Dr. Hutchinson Regional Medical Hutchinson, KS 67502-2552 · Center ./ Cassie Dolen CFO $200.00 09/05/2014 404 N. Fern Circle Hutchinson Regional Medical Sedgwick, KS 67135-3505 Center ./ William Giersch $100.00 09/05/2014 5713 N. Lorriane Hutchinson Regional Medical Hutchinson, KS 67502-8750 Center ./ Kevin Chiles VP Human Resources $100.00 09/05/2014 1200 N. Autumn Drive Hutchinson Regional Medical Goddard, KS 67052-8444 Center ./ ichard Miller Administrator and Chief Executive $250.00 09/05/2014 10 Valley Vista Officer orion, KS 67654-0250 Norton County Hospital ./ $1.350.00 Page _4__ of-22._ U.L / Ul:l / ZU.Lt> .Lt>:3l:I l<AA. Kansas Hospital Assoc 141006 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than SlSO Loan or Other Ca1h Check Loan !l!!.ru!! Olher .Receipt Bob Page Chief Executive Officer $1,000.00 13413 W. 75th Ct. University of Kansas Hospital, The 09/05/2014 Shawnee, KS 66216-3078 ./ John Hart Chief Executive Officer S125.00 309 N. 9th SI. Fredonia Regional Hospital 09/05/2014 Fredonia, KS 66736-1421 ./ Lee Norman Chief Medical Officer $500.00 210 W 5th St University of Kansas Hospital, The 09/07/2014 #205 Kansas City, MO 64105-1166 Karen Shumate Chief Operating Officer $100.00 1753 E 980 Rd Lawrence Memorial Hospital 09/12/2014 Lawrence, KS 66049-9073 Bryan Coffey Chief Executive Officer $150.00 PO Box 1302 Hamilton County Hospital 09/16/2014 Syracuse, KS 67878-1302 Robin Coffey MD $150.00 PO Box 1302 Hamilton County Hospital 09/16/2014 Syracuse, KS 67878-1302 .t/ Matthew Bible Manager $100.00 09/17/2014 3901 W.