2021-11-15T13:37:45-06:00 2020-12-31 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2020-01-01 411801967 SIBLEY MEDICAL CENTER SIBL 5079642271 601 WEST CHANDLER STREET ARLINGTON MN 55307 AARON BLOOMQUIST CFO 5079642271 2021-11-12 1 AARON BLOOMQUIST 999009999 DARRYN MCGARVEY P00958683 6123764500 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z RIDGEVIEW SIBLEY MEDICAL CENTER MICHAEL PHELPS 500 SOUTH MAPLE ST WACONIA MN 55387 15157229 0 X WWW.SIBLEYMEDICAL.ORG X 1948 MN TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. 6 6 93 4 0 0 44935 1485998 14005711 13381970 184468 137785 175593 151476 14410707 15157229 337948 808 0 0 7019567 6443812 0 0 0 6901161 6859492 14258676 13304112 152031 1853117 20079851 24658526 5287214 7362061 14792637 17296465 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 11496270 808 13381970 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. 11496270 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 12 0 93 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 BRENT WORDELMAN 9524422191 500 S MAPLE ST WACONIA MN 55387 LISA PFARR BOARD MEMBER/CHAIR 0.40 X X 0 0 2350 DIANE BIAS-MOSEL TRUSTEE 0.40 X 0 0 1800 TIMOTHY DOLAN TRUSTEE 0.40 X 0 0 1800 WAYNE HUBIN TRUSTEE 0.40 2.00 X 0 0 900 LYLE RUD TRUSTEE 0.40 X 0 0 1800 DENNIS SCHULTZ TRUSTEE 0.40 X 0 0 1800 DEE THOMAS TRUSTEE 0.40 X 0 0 1800 MICHAEL PHELPS PRESIDENT / CEO 2.00 48.00 X 0 561195 64748 GORDON GABLENZ CIO & TREASURER 4.00 46.00 X 0 764988 83372 BEN NIELSEN COO 1.00 49.00 X 0 320292 15401 AARON BLOOMQUIST CFO 4.00 46.00 X 0 67505 27892 0 1713980 203663 0 0 1 0 EMPAC 500 S MAPLE ST WACONIA MN 55387 PHYSICIAN SERVICES 1267378 KRAUS ANDERSON CONSTRUCTION COMPANY 501 S 8TH ST MINNEAPOLIS MN 55404 CONSTRUCTION SERVICES 298201 CENTRAL MINNESOTA DIAGNOSTIC INC 525 10TH ST NE PO BOX 158 MILACA MN 56353 CT SCANS 154635 ALLSCRIPTS 24630 NETWORK PLACE CHICAGO IL 60673 IT SERVICES 150441 MAYO COLLABORATIVE SERVICE INC PO BOX 9146 MINNEAPOLIS MN 55480 LAB SERVICES 128538 5 1485998 1485998 NET PATIENT REVENUE 621610 13381970 13381970 13381970 55674 55674 51932 0 51932 51932 51932 82111 0 82111 82111 82111 1908 0 1908 1908 JOINT VENTURE INCOME 900099 82093 82093 MISCELLANEOUS INCOME 900099 15543 15543 97636 15157229 13381970 0 289261 X 808 808 12250 12250 5301185 5068059 233126 170720 166240 4480 580172 569937 10235 379485 371569 7916 55770 55770 17765 17765 2952235 2595431 356804 54058 40612 13446 244339 244339 19951 19951 4334 2082 2252 110983 110983 1168199 552110 616089 32377 32377 MEDICAL SUPPLIES 1149837 1146684 3153 OTHER EXPENSES 547587 376640 170947 BAD DEBT EXPENSE 341282 341282 0 MINNESOTA CARE TAX 114134 114134 46641 526 46115 13304112 11496270 1807842 0 1256193 4817519 888511 1131221 1713440 2116738 17168 0 276340 541902 392131 456159 16792545 4756544 12742781 12036001 2536367 3306406 256920 252580 20079851 24658526 391315 304238 2905641 3403114 3141755 1492785 1010427 5287214 7362061 X 14792637 17296465 14792637 17296465 20079851 24658526 1853117 650711 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 460 460 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 1176702 3682940 7260828 409618 6851210 4524929 3170224 1354705 147146 147146 12036001 THIRD PARTY PAYOR SETTLEMENTS 750533 DUE TO RELATED ORGANIZATIONS 259894 1010427 X 14678162 -120020 -120020 14798182 17765 341282 359047 15157229 12945065 0 12945065 17765 341282 359047 13304112 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE 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 2D - OTHER ADJUSTMENTS: INVESTMENT INCOME -120,020. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 341,282. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 341,282. 1 1 X 1 X 1 X 225.000000000000 1 1 0 0 200990 200990 0.01510 2333245 1681920 651325 0.04900 2534235 1681920 852315 0.06410 4 153 458505 453144 5361 0.00040 4 153 458505 453144 5361 0.00040 4 153 2992740 2135064 857676 0.06450 1 341282 0 6967906 7060292 -92386 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 150.000000000000 225.000000000000 X X X 0 1 X X X X 1 X WWW.SIBLEYMEDICAL.ORG/FINANCIAL-ASSISTANCE/ X WWW.SIBLEYMEDICAL.ORG/FINANCIAL-ASSISTANCE/ X WWW.SIBLEYMEDICAL.ORG/FINANCIAL-ASSISTANCE/ 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. 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: ELIGIBILITY FOR SIBLEY MEDICAL CENTER'S CHARITY CARE PROGRAM IS BASED ON FAMILY INCOME RELATIVE TO 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 UP TO 225% OF FPG. PATIENTS SEEKING ASSISTANCE MAY FIRST BE ASKED TO APPLY FOR OTHER EXTERNAL PROGRAMS (SUCH AS MEDICAID OR INSURANCE THROUGH THE PUBLIC MARKETPLACE) AS APPROPRIATE BEFORE ELIGIBILITY UNDER THIS POLICY IS DETERMINED. IF INSURANCE IS GRANTED, BUT NOT RETROACTIVELY, SIBLEY MEDICAL CENTER MAY STILL GIVE FINANCIAL ASSISTANCE TO THE INDIVIDUAL FOR PAST MEDICAL SERVICES. ADDITIONALLY, ANY UNINSURED PATIENTS WHO ARE BELIEVED TO HAVE THE FINANCIAL ABILITY TO PURCHASE HEALTH INSURANCE MAY BE ENCOURAGED TO DO SO TO HELP ENSURE HEALTHCARE ACCESSIBILITY AND OVERALL WELL-BEING. OTHER FACTORS THAT MAY QUALIFY AN ACCOUNT FOR FINANCIAL ASSISTANCE MAY INCLUDE:A. THE PATIENT HAS ENDURED A FINANCIAL HARDSHIP.B. THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE BASED ON THE INCOME/FAMILY LEVELS AS DEFINED IN THIS POLICY.C. THE FACILITY HAS RECEIVED NOTICE FOR A PERSON WHO DECLARES BANKRUPTCY.D. THE FACILITY HAS NEGOTIATED AND SETTLED FOR AN AMOUNT LESS THAN THE FULL BALANCE OF A PATIENT'S ACCOUNT. THE NEGOTIATED DISCOUNTED AMOUNT MAY QUALIFY AS FINANCIAL ASSISTANCE.E. THE PATIENT HAS EXPIRED LEAVING NO ESTATE.F. THE PATIENT HAS EXPERIENCED A CATASTROPHIC HEALTH RELATED CIRCUMSTANCE.DETERMINATIONS FOR FINANCIAL ASSISTANCE ELIGIBILITY WILL REQUIRE PATIENTS TO SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION (INCLUDING ALL DOCUMENTATION REQUIRED BY THE APPLICATION) AND MAY REQUIRE APPOINTMENTS OR DISCUSSION WITH HOSPITAL FINANCIAL COUNSELORS. WHEN DETERMINING PATIENTS' ELIGIBILITY FOR FINANCIAL ASSISTANCE, RIDGEVIEW SIBLEY MEDICAL CENTER DOES NOT TAKE INTO ACCOUNT RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, OR SOCIAL OR IMMIGRANT STATUS. 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, LN 7 COL(F): BAD DEBT EXPENSES INCLUDED ON FORM 990, PART IX, LINE 24, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $341,282 FOR THE YEAR ENDED DECEMBER 31, 2020. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 3: SIBLEY MEDICAL CENTER HAS NOT IDENTIFIED A METHOD OF REASONABLY ESTIMATING THE PORTION OF ITS BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE BUT DID NOT COMPLETE AN APPLICATION. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: SIBLEY MEDICAL CENTER USED THE 2020 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 $92,386 IN 2020. THIS IS A DIRECT BENEFIT TO THE MEDICARE POPULATION OF OUR COMMUNITY. PART III, LINE 9B: AT ANY POINT DURING THE BILLING AND COLLECTION PROCESS A PATIENT HAS THE ABILITY TO REQUEST AN APPLICATION FOR FINANCIAL ASSISTANCE. ONCE AN APPLICATION HAS BEEN REQUESTED, THE COLLECTION PROCESS PAUSES AND DOES NOT CONTINUE UNTIL A DETERMINATION IS MADE FOR FINANCIAL ASSISTANCE. 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 4: SIBLEY COUNTY INCLUDES SEVEN CITIES. IN AGGREGATE, THE LAND SIZE IS 601 SQUARE MILES WITH A TOTAL POPULATION OF 14,733 PEOPLE (AS OF 2020). 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 2019 US CENSUS, THERE ARE 14,865 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 28.6%, THOSE 65 YEARS AND OVER AT 18.9%. THE POPULATION DECREASED -2.4% 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 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 (DBA: 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 MEDICAL CENTER ALSO HAS CLINICAL LOCATIONS IN ARLINGTON, GAYLORD, HENDERSON AND WINTHROP.MINNESOTA VALLEY HEALTH CENTER (DBA: RIDGEVIEW LE SUEUR MEDICAL CENTER) OPERATES A 15-BED ACCUTE CARE HOSPITAL, A 55-BED NURSING HOME, AND A 37-UNIT HUD APARTMENT BUILDING FOR THE ELDERLY.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 AN ACCOUNTABLE CARE ORGANIZATION. RIDGEVIEW INSURANCE COMPANY OPERATES A CAPTIVE INSURANCE COMPANY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER. RIDGEVIEW FOUNDATION OPERATES FOR THE EXCLUSIVE BENEFIT OF RIDGEVIEW MEDICAL CENTER. 1 0 1 0 0 0 1 1 0 0 GORDON GABLENZ CIO & TREASURER 0 290231 0 56602 0 418155 0 22910 0 60462 0 848360 0 0 MICHAEL PHELPS PRESIDENT / CEO 0 466890 0 91332 0 2973 0 25176 0 39572 0 625943 0 0 BEN NIELSEN COO 0 259023 0 37452 0 23817 0 14647 0 754 0 335693 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 AT RIDGEVIEW MEDICAL CENTER. DURING 2020, $0 WAS CONTRIBUTED TO THE PLAN, $24,880 WAS ACCRUED WITHIN THE PLAN, AND $0 WAS PAID OUT OF THE PLAN. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2020, $414,540 WAS CONTRIBUTED TO THE PLAN, $37,525 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 2018 AND PAID IN 2019. 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 2,595,431. MANAGEMENT AND GENERAL EXPENSES 356,804. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,952,235. 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