2022-11-14T13:31:56-06:00 2021-12-31 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2021-01-01 411801967 SIBLEY MEDICAL CENTER SIBL 5079642271 601 WEST CHANDLER STREET ARLINGTON MN 55307 AARON BLOOMQUIST CFO 5079642271 2022-11-11 1 AARON BLOOMQUIST XXX-XX-XXXX DARRYN MCGARVEY P00958683 6123764500 2022-11-11 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z RIDGEVIEW SIBLEY MEDICAL CENTER MICHAEL PHELPS 500 SOUTH MAPLE ST WACONIA MN 55387 19084797 0 X WWW.RIDGEVIEWMEDICAL.ORG X 1948 MN TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. 6 6 109 0 0 0 1485998 33702 13381970 18005049 137785 124756 151476 136852 15157229 18300359 808 70863 0 0 6443812 7024611 0 0 0 6859492 7507219 13304112 14602693 1853117 3697666 24658526 31684088 7362061 9983374 17296465 21700714 RIDGEVIEW SIBLEY MEDICAL CENTER EXISTS TO ENHANCE THE LIFELONG HEALTH OF PEOPLE IT SERVES WITH A CULTURE THAT NURTURES THE WHOLE PERSON: MIND, BODY, AND SPIRIT. 0 0 10652693 70863 18005049 LOCATED IN ARLINGTON, MINNESOTA, RIDGEVIEW SIBLEY MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL--PROVIDING URGENT CARE, GENERAL SURGERY, AND 24/7 HOSPITAL AND EMERGENCY SERVICES TO RESIDENTS OF SIBLEY COUNTY AND THE SURROUNDING AREA. RIDGEVIEW SIBLEY ALSO HAS CLINIC LOCATIONS IN ARLINGTON, GAYLORD, HENDERSON AND WINTHROP.RIDGEVIEW SIBLEY MEDICAL CENTER BELIEVES EVERYONE DESERVES TOP-QUALITY MEDICAL CARE AND THAT THE PEOPLE OF SIBLEY COUNTY SHOULDN'T HAVE TO TRAVEL FAR TO GET THE LATEST MEDICAL ADVANCEMENTS. IT'S THIS BELIEF THAT DRIVES US TO BRING SPECIALTY CARE TO OUR COMMUNITY. IT'S WHY WE CONSTANTLY PURSUE THE TECHNOLOGIES, RECRUIT THE EXPERTS, AND EXPAND AND IMPROVE FACILITIES THAT MAKE GREAT HEALTH CARE POSSIBLE. 10652693 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 11 0 109 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 MN X AARON BLOOMQUIST 9524422191 500 S MAPLE ST WACONIA MN 55387 MICHAEL PHELPS PRESIDENT/CEO 2.00 48.00 X 0 1197762 68637 GORDON GABLENZ CIO 4.00 46.00 X 0 801951 87436 AARON BLOOMQUIST CFO 4.00 46.00 X 0 276340 59127 BENJAMIN NIELSEN COO 1.00 49.00 X 0 298901 14170 STACEY LEE VICE PRESIDENT 0.00 50.00 X 0 24666 0 WAYNE HUBIN BOARD MEMBER 0.40 4.00 X 2400 5000 0 LISA PFARR CHAIR 0.40 0.00 X X 1800 0 0 DIANE BIAS-MOSEL SECRETARY 0.40 0.00 X X 1200 0 0 DENNIS SCHULTZ TREASURER (THROUGH JULY 2021) 0.40 0.00 X X 700 0 0 TIMOTHY DOLAN BOARD MEMBER 0.40 0.00 X 1200 0 0 LYLE RUD BOARD MEMBER 0.40 0.00 X 1200 0 0 DEE THOMAS BOARD MEMBER 0.40 0.00 X 1200 0 0 9700 2604620 229370 0 0 1 0 EMPAC 500 S MAPLE ST WACONIA MN 55387 PHYSICIAN SERVICES 1177018 CMDI PO BOX 158 MILACA MN 56353 CT SCANS 198738 ASSOCIATED MECHANICAL SERVICES 1257 MARSCHALL ROAD SHAKOPEE MN 55379 HVAC SERVICES 102202 3 33702 33702 NET PATIENT REVENUE 621610 18005049 18005049 18005049 65953 65953 45513 0 45513 45513 45513 841941 1300 784438 0 57503 1300 58803 58803 1332 0 1332 1332 JOINT VENTURE INCOME 900099 111463 111463 MISCELLANEOUS INCOME 900099 -21456 -21456 90007 18300359 18005049 0 261608 X 70863 70863 9700 9700 5771545 4605103 1166442 180648 145718 34930 640506 470584 169922 422212 345932 76280 58516 58516 13735 13735 2881859 2152543 729316 13717 13717 65347 54981 10366 281215 177751 103464 19795 16789 3006 5792 3951 1841 102555 102555 1178125 87429 1090696 40739 40739 MEDICAL SUPPLIES 2001600 1979936 21664 OTHER EXPENSES 505170 374226 130944 BAD DEBT EXPENSE 152860 152860 MINNESOTA CARE TAX 139790 139790 46404 310 46094 14602693 10652693 3950000 0 4817519 7109796 1131221 1646605 2116738 6315330 541902 440000 456159 192669 17025743 5934668 12036001 11091075 3306406 4595793 5298 252580 287522 24658526 31684088 304238 557792 2905641 820129 3141755 2873855 1010427 5731598 7362061 9983374 X 17296465 21700714 17296465 21700714 24658526 31684088 3697666 706583 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 148 148 0 PART II-B, LINE 1: SIBLEY MEDICAL CENTER PAYS DUES TO THE MINNESOTA HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION, A PORTION OF WHICH ARE USED FOR LOBBYING EXPENSES. 4859642 1345674 3513968 7302618 844756 6457862 4728322 3744238 984084 135161 135161 11091075 THIRD PARTY PAYOR SETTLEMENTS 2038386 DUE TO RELATED ORGANIZATIONS 3693212 5731598 X 17955400 0 17955400 13735 331224 344959 18300359 14367455 0 14367455 13735 221503 235238 14602693 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE IRC THAT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(C)(3) OF THE CODE. THE ORGANIZATION HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST INCOME 52,218. REALIZED GAINS 57,512. BAD DEBT EXPENSE 152,860. GRANTS TO RELATED ORGANIZATIONS 68,634. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 152,860. GRANTS TO RELATED ORGANIZATIONS 68,643. 1 1 X 1 X 1 X 1 1 0 0 175158 175158 0.01210 1455078 719177 735901 0.05090 1630236 719177 911059 0.06300 3 12 16137 16137 0.00110 1 200 200 0.00000 4 12 16337 16337 0.00110 4 12 1646573 719177 927396 0.06410 1 152860 38215 7146822 7163361 -16539 X 1 1 1 1 RIDGEVIEW SIBLEY MEDICAL CENTER 601 WEST CHANDLER STREET ARLINGTON MN 55307 WWW.SIBLEYMEDICAL.ORG HFID-00618 X X X X RIDGEVIEW SIBLEY MEDICAL CENTER 1 0 0 1 X X X X X X X X X 19 1 1 1 1 X WWW.RIDGEVIEWMEDICAL.ORG/ABOUT-US/ X 1 19 1 WWW.RIDGEVIEWMEDICAL.ORG/ABOUT-US/ 0 1 X 200.000000000000 250.000000000000 X X X 1 1 X X X X 1 X SEE LINE 16J X SEE LINE 16J X SEE LINE 16J X X X X X 1 X 0 X X X X 1 X 0 0 RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 5: RIDGEVIEW PARTNERED WITH CARVER COUNTY PUBLIC HEALTH TO COMPLETE THE PRIMARY DATA COLLECTION FOR THE 2019 CHNA. THIS INCLUDED PRIMARY RESEARCH, DATA ANALYSIS, VALIDATION AND PRIORITIZATION, AND ANALYSIS OF DOCUMENTED HEALTH AND SOCIOECONOMIC FACTORS WITH COMMUNITY INPUT. THE COMMUNITY INPUT INCLUDED SURVEYS FROM RESIDENTS OF CARVER COUNTY PLUS ACROSS THE SIX OTHER COUNTIES IN RIDGEVIEW'S SERVICE AREA. THIS PRIMARY DATA WSA SUPPLEMENTED WITH SECONDARY DATA* COLLECTED FROM THE FOLLOWING SOURCES (BUT NOT LIMITED TO): RIDGEVIEW'S ELECTRONIC MEDICAL RECORD AND FINANCIAL SYSTEMS, US CENSUS BUREAU, COUNTY HEALTH RANKINGS, MINNESOTA HOSPITAL ASSOCIATION. SEE APPENDIX C FOR 2018 COMMUNITY ADULT HEALTH SURVERY. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 6A: THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED WITH RIDGEVIEW MEDICAL CENTER. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 6B: CARVER COUNTY PUBLIC HEALTH RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 11: RIDGEVIEW SIBLEY MEDICAL CENTER CONTINUES TO DEVELOP BROAD COMMUNITY STRATEGIES THAT FOCUS ON FOUR HEALTH ISSUES THAT WERE IDENTIFIED AND PRIORITIZED IN THE CHNA AND IMPLEMENTATION PLAN: 1) PREVENTION, CLINICAL CARE, AND DISEASE MANAGEMENT (PREVENTATIVE SCREENINGS, ACCESS TO CARE - RURAL SERVICE AREA), 2) AGING AND AGING-RELATED CONCERNS (SENIOR SERVICES, TRANSPORTATION), 3) MENTAL AND BEHAVIORAL HEALTH (EMERGENCY SERVICES, ADULT BEHAVIORAL HEALTH). RIDGEVIEW WILL CONTINUE TO OFFER CARE AND SERVICES TO ADDRESS THESE PRIORITY HEALTH ISSUES. THE INFORMATION FROM THE CHNA WILL FURTHER INFORM ORGANIZATIONAL LEADERSHIP IN DECISION-MAKING PROCESSES TO EXPAND, REFINE, AND DIRECT SERVICES, COMMUNICATION, COLLABORATION, EDUCATION AND OUTREACH ACTIVITIES. ADDRESSING THE PRIORITY HEALTH ISSUES INVOLVES MANY FACTORS OUTSIDE THE CLINICAL SETTING, RIDGEVIEW WILL CONTINUE TO WORK TO ENHANCE THE IMPACT OF BROADER COMMUNITY HEALTH EFFORTS TO ADDRESS THESE ISSUES. BY FACILITATING SYSTEM-WIDE AND CROSS-COMMUNITY COMMUNICATION AND COLLABORATION, EXISTING EFFORTS WILL RESULT IN IMPROVED SUCCESS AND IMPACT. WHILE EMPHASIS IS PLACED ON THE THREE HEALTH ISSUES DETAILED IN THE CHNA REPORT DOCUMENT, RIDGEVIEW AS A COMMUNITY HEALTH PROVIDER, WILL CONTINUE TO FOCUS RESOURCES ON OTHER LONG-STANDING INITIATIVES AND SERVICES THAT HELP IMPROVE OVERALL HEALTH. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND APPLICATION ARE AVAILABLE AT WWW.RIDGEVIEWMEDICAL.ORG/PATIENTS-VISITORS/FINANCIAL/. 4 1 - RIDGEVIEW ARLINGTON CLINIC 601 WEST CHANDLER STREET ARLINGTON MN 55307 CLINIC 2 - RIDGEVIEW GAYLORD CLINIC 660 3RD STREET GAYLORD MN 55334 CLINIC 3 - RIDGEVIEW HENDERSON CLINIC 505 MAIN STREET HENDERSON MN 56044 CLINIC 4 - RIDGEVIEW WINTHROP CLINIC 223 NORTH CARVER STREET WINTHROP MN 55396 CLINIC PART I, LINE 3C: TO QUALIFY FOR FINANCIAL ASSISTANCE, THE FOLLOWING CONDITIONS MUST BE MET:(A) THE MEDICAL CARE PROVIDED BY SIBLEY MEDICAL CENTER IS MEDICALLY NECESSARY;(B) THE INDIVIDUAL SUBMITS A COMPLETED APPLICATION;(C) THE INDIVIDUAL COOPERATES WITH THE HOSPITAL TO EXPLORE ALTERNATIVE MEANS OF ASSISTANCE, IF NECESSARY (INCLUDING SSI, DISABILITY, MEDICARE AND MEDICAID); AND(D) THE INDIVIDUAL'S FAMILY INCOME IS LESS THAN 250% OF FEDERAL POVERTY GUIDELINES ("FPG"). FREE CARE IS OFFERED FOR FEDERAL ADJUSTED GROSS INCOME UP TO 200% OF FPG. 75% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME BETWEEN 200% AND 225% FPG. 56% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME BETWEEN 225% AND 250% OF FPG.IN ADDITION, PATIENTS SEEKING FINANCIAL ASSISTANCE MAY BE ASKED FIRST TO APLY FOR OTHER EXTERNAL PROGRAMS (SUCH AS MEDICAID OR INSURANCE THROUGH THE PUBLIC MARKETPLACE).SIBLEY MEDICAL CENTER MAY RELY ON EXTERNAL SOURCES TO DETERMINE ELIGIBILITY WHEN:(A) THE PATIENT IS HOMELESS;(B) THE PATIENT IS ELIGIBLE FOR OTHER UNFUNDED STATE OR LOCAL ASSISTANCE PROGRAMS;(C) THE PATIENT IS ELIGIBLE FOR FOOD STAMPS OR SUBSIDIZED SCHOOL LUNCH;(D) THE PATIENT IS ELIGIBLE FOR STATE-FUNDED PRESCRIPTION MEDICATION;(E) THE PATIENTS VALID ADDRESS IS CONSIDERED LOW-INCOME OR SUBSIDIZED HOUSING; OR(F) THE PATIENT RECEIVEDS FREE CARE FROM A COMMUNITY CLINIC AND IS REFERRED TO THE HOSPITAL FOR FURTHER TREATMENT.SIBLEY MEDICAL CENTER ALSO USES CHANGE HEALTHCARE, AN ELIGIBILITY VENDOR, TO HELP IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART I, LINE 7: THE COSTING METHODOLOGY USED BY SIBLEY MEDICAL CENTER TO DETERMINE THE COMMUNITY BENEFIT EXPENSES INCLUDED IN PART I, LINES 7A-D WERE DERIVED BY TAKING THE RESPECTIVE AMOUNTS PER THE AUDITED FINANCIAL STATEMENTS AND APPLYING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. THE COMMUNITY BENEFIT EXPENSES INCLUDED IN LINES 7E-J WERE REPORTED BASED ON SMC'S ACTUAL COSTS FOR EACH CLASSIFICATION OF EXPENSES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 152,860. PART III, LINE 2: THE AMOUNT OF BAD DEBT EXPENSE INCLUDED IN PART III, LINE 2 IS CALCULATED BY RIDGEVIEW AS FOLLOWS: PAYMENT FOR SERVICES IS REQUIRED WITHIN 30 DAYS OF RECEIPT OF THE INVOICE OR CLAIM SUBMITTED. PATIENT ACCOUNTS THAT ARE MORE THAN 90 DAYS PAST DUE ARE INDIVIDUALLY ANALYZED FOR COLLECTIBILITY. IN ADDITION, AN ALLOWANCE IS ESTIMATED FOR OTHER ACCOUNTS BASED ON HISTORICAL EXPERIENCE OF THE ORGANIZATION. WHEN ALL COLLECTION EFFORTS HAVE BEEN EXHAUSTED, THE ACCOUNT IS WRITTEN OFF AGAINST THE RELATED ALLOWANCE. PART III, LINE 3: SIBLEY MEDICAL CENTER ESTIMATES THAT APPROXIMATELY 25% OF ITS TOTAL COST OF CHARITY CARE IS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE BUT DID NOT COMPLETE AN APPLICATION AND WERE ULTIMATELY INCLUDED IN BAD DEBT EXPENSE REPORTED IN PART III, LINE 2. PART III, LINE 4: SEE NOTE 2, "PATIENT SERVICE REVENUE", ON PAGES 10-14 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF SIBLEY MEDICAL CENTER'S BAD DEBT EXPENSE. PART III, LINE 8: SIBLEY MEDICAL CENTER USED THE 2021 FILED MEDICARE COST REPORT TO CALCULATE THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6. APPLIED AGAINST ACTUAL RECEIPTS, SIBLEY EXPERIENCED COSTS NOT COVERED BY MEDICARE IN THE AMOUNT OF $16,539 IN 2021. THIS IS A DIRECT BENEFIT TO THE MEDICARE POPULATION OF OUR COMMUNITY. PART III, LINE 9B: RIDGEVIEW'S CHARITY PROGRAM ALLOWS FOR ACCOUNTS IN BAD DEBT STATUS TO COMPLETE A CHARITY CARE APPLICATION. IF APPROVED, THE ACCOUNT WILL BE RETURNED FROM BAD DEBT AND APPLIED TO OUR CHARITY CARE PROGRAM. ALL PATIENTS ARE ADVISED OF OUR CHARITY CARE PROGRAM THROUGH OUR MONTHLY BILLING PROCESS. RIDGEVIEW MEDICAL CENTER DOES NOT CHARGE INTEREST ON OUTSTANDING PATIENT ACCOUNT BALANCES. PART VI, LINE 2: SIBLEY MEDICAL CENTER ASSESSES THE CURRENT HEALTH STATUS, HEALTH OUTCOMES, AND UNMET NEEDS IN THE COMMUNITIES IT SERVES THROUGH A FORMALIZED, RIGOROUS, AND STRUCTURED PROCESS. COMPLETION OF THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND PUBLIC REPORTING ENSURES THAT SIBLEY MEDICAL CENTER IMPROVEMENT EFFORTS AND RESOURCES ARE ALIGNED WITH COMMUNITY HEALTH PRIORITIES.SIBLEY MEDICAL CENTER HAS AND WILL CONTINUE TO USE A CHNA AND OTHER INTERNAL AND EXTERNAL INFORMATION (INCLUDING DISCHARGE, QUALITY MEASURES, PREDICTIVE, AND POPULATION DATA) TO AID STRATEGIC PLANNING PROCESSES AND ALIGN ORGANIZATIONAL SERVICES/RESOURCES ACCORDINGLY. PART VI, LINE 3: AT THE TIME OF SCHEDULING, PRE-REGISTRATION, REGISTRATION, OR DISCHARGE (WHICHEVER IS APPLICABLE), THE PATIENT WILL BE ASKED FO INSURANCE COVERAGE, AND THE PATIENT WILL BE INFORMED OF ANY CO-PAYMENTS THAT WILL BE EXPECTED AT THE TIME OF PAYMENT. IF THE PATIENT WISHES TO APPLY FOR COMMUNITY CARE, HE OR SHE WILL BE GIVEN OR MAILED AN APPLICATION; THE APPLICATION IS ALSO AVAILABLE FOR DOWNLOAD FROM THE RMC WEBSITE. A PATIENT MAY NOT QUALIFY FOR COMMUNITY CARE UNTIL HE OR SHE HAS COMPLETED THE APPLICATION. AFTER COMPLETING THE COMMUNITY CARE APPLICATION (INCLUDING SUPPORTING DOCUMENTATION), THE ACCOUNT REPRESENTATIVE WILL ASSESS THE APPLICATION AND DETERMINE WHETHER THE PATIENT QUALIFIES FOR COMMUNITY CARE OR ANY OTHER GOVERNMENTAL HEALTH CARE COVERAGE. IF THE PATIENT IS LIKELY TO QUALIFY FOR THE HOSPITAL PRESUMPTIVE ELIGIBILITY PROGRAM OTHER GOVERNMENTAL HEALTH CARE COVERAGE, THE ACCOOUNT REPRESENTATIVE WILL DETERMINE APPROPRIATE COVERAGE AND REFER THE PATIENT AS APPROPRIATE. IF AN UNINSURED PATIENT IS UNLIKELY TO QUALIFY FOR GOVERNMENTAL HEALTH CARECOVERAGE, OR DENIED HOSPITAL PRESUMPTIVE ELIGIBILITY, AND THE PATIENT DOES NOT QUALIFY FOR COMMUNITY CARE, APPROPRIATE PAYMENT ARRANGEMENTS MUST BE MADE WITH THE ACCOUNT REPRESENTATIVE BASED UPON RMC'S UNINSURED PAYMENT POLICY. SHOULD THE PATIENT SUBSEQUENTLY QUALIFY FOR GOVERNMENTAL HEALTH CARE COVERAGE OR ANY OTHER HEALTH INSURANCE, ANY PAYMENTS RECEIVED WILL BE REFUNDED LESS ANY CO-PAYMENTS DUE. THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND APPLICATION ARE AVAILABLE AT WWW.RIDGEVIEWMEDICAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/PAY-YOUR-BILL-ONLINE. PART VI, LINE 4: SIBLEY COUNTY INCLUDES SEVEN CITIES. IN AGGREGATE, THE LAND SIZE IS 601 SQUARE MILES. SIBLEY COUNTY IS CONSIDERED A "FRINGE" COUNTY AND IS ON THE WESTERN BOUNDARY OF THE SEVEN-COUNTY TWIN CITIES METEROPOLITAN AREA. THE DISTINCT QUALITIES OF EACH COMMUNITY PROVIDE A UNIQUE BLEND OF HISTORY AND CULTURE. MANY COMMUNTERS TAKE ADVANTAGE OF OUR LOWER HOUSING COSTS AND THE BENEFITS OF RURAL LIVING. AGRICULTURE IN SIBLEY COUNTY IS A MAIN SOURCE OF EMPLOYMENT AND INCOME. THERE ARE 352,000 ACRES DEDICATED TO FARMING. OF THESE FARMS, 86.55% OF THEM ARE INDIVIDUALLY/FAMILY OWNED AND OPERATED. THE AVERAGE VALUE FO THE AGRICULTURAL PRODUCTS SOLD PER FARM IS $175,079. ALONG WITH THE PRODUCTION FO CROPS, A LARGE NUMBER OF FARMS RAISE LIVESTOCK, POULTRY, AND DAIRY CATTLE. ACCORDING TO THE 2021 US CENSUS, THERE ARE 14,601 PEOPLE LIVING IN SIBLEY COUNTY, WITH THE MAJORITY OF THE POPULATION RESIDING IN THE CITIES OF ARLINGTON, GAYLORD, AND WINTHROP. THE POPLULATION BREAKDOWN SHOWS THOSE UNDER 18 YEARS OF AGE AT 28.5%, THOSE 65 YEARS AND OVER AT 18.9%. THE POPULATION DECREASED -5.16% SINCE 2010, BUT OVERALL THE POPULATION HAS STAY CONSISTENT OVER THE LAST DECADE. PART VI, LINE 5: SIBLEY MEDICAL CENTER PROVIDES COMMUNITY EDUCATION AND WORKS WITH HEALTH CARE PROVIDERS IN MEEKER, MCLEOD AND SIBLEY COUNTIES TO IMPROVE THE HEALTH OF OUR COMMUNITY. PART VI, LINE 6: SIBLEY MEDICAL CENTER IS A SUBSIDIARY OF RIDGEVIEW MEDICAL CENTER. RIDGEVIEW MEDICAL CENTER IS A 109-BED ACUTE CARE HOSPITAL IN WACONIA, MINNESOTA THAT PROVIDES HEALTHCARE SERVICES TO THE RESIDENTS OF THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MN. RIDGEVIEW MEDICAL CENTER'S SUBSIDIARIES INCLUDE:RIDGEVIEW CLINICS, WHICH PROVIDES OUTPATIENT HEALTHCARE SERVICES FROM VARIOUS CLINIC LOCATIONS THROUGHOUT THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MINNESOTA. SIBLEY MEDICAL CENTER OPERATES AN AMBULATORY SURGICAL CENTER. CHASKA PLAZA SURGERY CENTER IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER OWNS A 51% INTEREST. MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER PROVIDES CARDIOLOGY SERVICES. THE HEART INSTITUTE IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER HOLDS A 50% INTEREST. WACONIA BUILDING INVESTMENTS OWNS A MEDICAL OFFICE BUILDING ON RIDGEVIEW MEDICAL CENTER'S CAMPUS. RIDGEVIEW REAL ESTATE LLC HOLDS THE LAND LEASE FOR WACONIA BUILDING INVESTMENTS. RIDGEVIEW COMMUNITY NETWORK OPERATES A AN ACCOUNTABLE CARE ORGANIZATION. RIDGEVIEW INSURANCE COMPANY OPERATES A CAPTIVE INSURANCE COMPANY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER. RIDGEVIEW FOUNDATION OPERATE FOR THE EXCLUSIVE BENEFIT OF RIDGEVIEW MEDICAL CENTER. 1 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 501(C)(3) 68634 0 GENERAL OPERATING SUPPORT 1 0 PART I, LINE 2: TRANSFERS ARE TO RELATED ENTITIES UNDER COMMON MANAGEMENT AND TRACKED THROUGH THE INTERNAL REPORTING PROCESS. 0 1 0 0 0 1 1 0 0 MICHAEL PHELPS PRESIDENT/CEO 0 530661 0 0 0 667101 0 28337 0 40300 0 1266399 0 0 GORDON GABLENZ CIO 0 313342 0 0 0 488609 0 25560 0 61876 0 889387 0 0 AARON BLOOMQUIST CFO 0 275606 0 0 0 734 0 13627 0 45500 0 335467 0 0 BENJAMIN NIELSEN COO 0 274784 0 0 0 24117 0 13416 0 754 0 313071 0 0 PART I, LINE 3 THE ADMINISTRATOR'S COMPENSATION IS DETERMINED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. THE FOLLOWING WERE USED BY RIDGEVIEW MEDICAL CENTER TO DETERMINE THE ADMINISTRATOR'S COMPENSATION: 1. COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) PART I, LINE 4B MICHAEL PHELPS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2021, $621,440 WAS CONTRIBUTED TO THE PLAN, $42,739 WAS ACCRUED WITHIN THE PLAN, AND $0 WAS PAID OUT OF THE PLAN. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2021, $434,954 WAS CONTRIBUTED TO THE PLAN, $50,027 ACCRUED WITHIN THE PLAN, AND $0 WAS PAID OUT OF THE PLAN. THESE DEFERRED COMPENSATION AMOUNTS ARE REPORTED ON A PRO-RATA BASIS WITHOUT REGARD TO THE INDIVIDUAL'S VESTING SCHEDULE. CURRENTLY, THE MAJORITY OF DEFERRED COMPENSATION IS NOT VESTED. PART I, LINE 6 THE OFFICERS OF RIDGEVIEW MEDICAL CENTER AND AFFILIATES RECEIVE BONUSES CONTINGENT ON THE NET EARNINGS OF THE CONSOLIDATED ENTITY AND GOALS ACHIEVED. BONUSES WERE EARNED IN 2021 AND PAID IN 2022. FORM 990, PART VI, SECTION A, LINE 3 ALL MANAGEMENT SERVICES ARE PROVIDED BY RIDGEVIEW MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 6 RIDGEVIEW MEDICAL CENTER IS THE SOLE MEMBER OF RIDGEVIEW SIBLEY MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A DIRECTORS ARE ELECTED BY THE RIDGEVIEW MEDICAL CENTER BOARD. ANY DIRECTOR MAY ALSO BE REMOVED BY THE RIDGEVIEW MEDICAL CENTER BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE BOARD OF DIRECTORS WILL CARRY OUT THE DUTIES NORMALLY ASSOCIATED WITH A NONPROFIT HOSPITAL BOARD OF DIRECTORS, SUBJECT TO THE RESERVED POWERS OF THE MEMBER AND THE CITY BELOW. THE MEMBER RESERVES AUTHORITY WITH REGARD TO THE MATTERS LISTED BELOW, SUBJECT TO THE RESERVED POWERS OF THE CITY INCLUDED THEREAFTER. THE MEMBER WILL LOOK TO THE BOARD TO MAKE RECOMMENDATIONS ON DECISIONS ON MATTERS LISTED BELOW, BUT THE MEMBER IS NOT REQUIRED TO ACCEPT SUCH RECOMMENDATIONS, AND THE MEMBER MAY TAKE ACTION ON ITS OWN IN SUCH AREAS, SUBJECT TO THE CITY'S RESERVED POWERS. THE MEMBER'S APPROVAL WILL BE REQUIRED FOR ANY ACTION PROPOSED BY THE BOARD IN THESE AREAS: (A) FINAL APPOINTMENT OF BOARD MEMBERS; (B) ISSUANCE OF DEBT BY THE CORPORATION; (C) SALE OF SUBSTANTIAL ASSETS OF THE CORPORATION; (D) CHANGES IN THE CORPORATION'S ARTICLES OF INCORPORATION AND BYLAWS; (E) ESTABLISHMENT OF ANOTHER MEMBER RELATIONSHIP BY THE CORPORATION OR ANOTHER FORM OF AFFILIATION; (F) STRATEGIC PLAN FOR THE CORPORATION; (G) OPERATING AND CAPITAL BUDGETS OF THE CORPORATION; (H) UNBUDGETED TOTAL ANNUAL CAPITAL EXPENDITURES; (I) AUDIT AND COMPLIANCE PROGRAMS; (J) ACCREDITATION PROGRAMS; (K) GROUP EMPLOYEE BENEFITS; (L) MANAGING THE CORPORATION'S CASH AND INVESTMENTS (THE MEMBER MAY MOVE FUNDS BETWEEN THE ORGANIZATIONS FREELY, SUBJECT TO BOND COVENANT OR TRUSTEE REQUIREMENTS); (M) THIRD PARTY PAYER CONTRACTING; (N) INSURANCE; (O) INFORMATION SYSTEM DESIGN AND IMPLEMENTATION; AND (P) GROUP PURCHASING. THE CITY'S APPROVAL WILL BE REQUIRED FOR THE DECISIONS OF THE BOARD IN THE FOLLOWING AREAS: (A) SALE OF ALL OR SUBSTANTIALLY ALL OF THE CORPORATION'S ASSETS; (B) SALE OF ASSETS ABOVE THRESHOLDS ALLOWED BY BOND COVENANTS; (C) ISSUANCE OF DEBT WHICH WOULD OBLIGATE THE CORPORATION IN EXCESS OF LEVELS ALLOWED BY BOND COVENANTS; AND (D) CHANGES TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWED THE FORM 990 AND PROVIDED COPIES TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ANNUALLY REVIEW AND SIGN THE STATEMENTS FOR POTENTIAL CONFLICTS OF INTEREST. EACH MEMBER IS EXPECTED TO DISCLOSE ANY CONFLICT OF INTEREST THAT MAY ARISE DURING THE YEAR. IF IT IS DETERMINED THAT A CONFLICT OF INTEREST EXISTS, THE SITUATION WILL BE EXAMINED AND HANDLED APPROPRIATELY BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ANY COMPENSATION RECEIVED BY OFFICERS OR BOARD MEMBERS IS DETERMINED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G MEDICAL SERVICES AND OTHER MISCELLANEOUS SERVICES: PROGRAM SERVICE EXPENSES 2,152,543. MANAGEMENT AND GENERAL EXPENSES 729,316. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,881,859. FORM 990, PART XII, LINE 2C THE PROCESS FOR OVERSIGHT AND SELECTION OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGE FROM THE PRIOR YEAR. RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 N/A 0 RIDGEVIEW FOUNDATION 500 SOUTH MAPLE STREET WACONIA MN 55387 411328097 RAISING FUNDS FOR RIDGEVIEW MEDICAL CENTER MN 501(C)(3) LINE 7 RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW INSURANCE COMPANY 60 E SOUTH TEMPLE STE 1800 SALT LAKE CITY UT 84111 454109041 CAPTIVE INSURANCE COMPANY UT 501(C)(3) LINE 12A, I RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW CLINICS 500 SOUTH MAPLE STREET WACONIA MN 55387 411651783 HEALTH CARE SERVICES MN 501(C)(3) LINE 12A, I RIDGEVIEW MEDICAL CENTER 0 MINNESOTA VALLEY HEALTH CENTER 621 SOUTH 4TH STREET LE SUEUR MN 56058 410837659 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER LLC 500 S MAPLE ST WACONIA MN 55387 205785920 CARDIOLOGY SERVICES MN N/A 0 0 CHASKA PLAZA SURGERY CENTER 3000 HUNDERTMARK RD CHASKA MN 55318 450975783 SURGERY SERVICES MN N/A 0 0 EXECUTIVE HEALTH MANAGEMENT SERVICES 500 SOUTH MAPLE STREET WACONIA MN 55387 411760239 MANAGEMENT SERVICES MN N/A C 0 CHARITABLE REMAINDER UNITRUST (1) CHARITABLE TRUST MN N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0