2018-11-15T16:16:39-06:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-01-01 411801967 SIBLEY MEDICAL CENTER SIBL 5079642271 601 WEST CHANDLER STREET ARLINGTON MN 55307 BRENT WORDELMAN DIRECTOR OF FINANCE 5079642271 2018-11-14 1 DARRYN MCGARVEY P00958683 6123764500 2018-11-14 67.137.57.251 2018-11-14 20:57:17 PS P FD302F4D5CE3C660ABAF9933EAAEEC9F457F14F9 9C3E08EBF53FA5FA3C7B2B5BD0B3E335DF999A73 2017 2019-02-21 02:37:17Z X RIDGEVIEW SIBLEY MEDICAL CENTER GORDON GABLENZ 500 SOUTH MAPLE ST WACONIA MN 55387 19665784 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. 8 8 112 5 0 0 186536 2572151 13167701 14820714 -32115 247571 276959 233050 13599081 17873486 0 8074 0 0 7561249 8295571 0 0 0 5114924 6516756 12676173 14820401 922908 3053085 16218668 20429114 5679983 6592625 10538685 13836489 X 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. 1 0 12300545 8074 14820714 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. 12300545 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 13 0 112 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 MN X DARLA ANDERSON 9524422191 601 WEST CHANDLER STREET ARLINGTON MN 55307 KEVIN LINDSTRAND CHAIR 0.50 0.00 X X 1800 0 0 DAVID WELCH TREASURER 0.50 0.00 X X 1200 0 0 LISA PFARR SECRETARY 0.50 0.00 X X 1200 0 0 TIMOTHY DOLAN TRUSTEE 0.50 0.00 X 1200 0 0 WAYNE HUBIN TRUSTEE 0.50 2.00 X 600 5000 0 BRENDA PAUTSCH TRUSTEE (THROUGH MAY 2017) 0.50 0.00 X 300 0 0 LYLE RUD TRUSTEE 0.50 0.00 X 1200 0 0 DENNIS SCHULTZ TRUSTEE 0.50 0.00 X 1200 0 0 DEE THOMAS TRUSTEE 0.50 0.00 X 1200 0 0 TODD SANDBERG RSMC ADMINISTRATOR 1.00 49.00 X 0 211704 40137 DARLA ANDERSON DIRECTOR OF FINANCE 1.00 49.00 X 0 92186 32390 MICHAEL PHELPS PRESIDENT / CEO 2.00 48.00 X 0 1450467 37854 ROBERT STEVENS PRESIDENT / CEO (THRU JUNE 2017) 2.00 48.00 X 0 1656460 32826 GORDON GABLENZ CFO & CIO 4.00 46.00 X 0 663997 45865 9900 4079814 189072 0 0 1 0 EMPAC 500 S MAPLE STREET WACONIA MN 55387 ED PHYSICIAN SERVICES 915458 CENTRAL MINNESOTA DIAGNOSTIC INC 150 10TH STREET NW PO BOX 158 MILACA MN 56353 CT SCANS 192699 TRUBRIDGECPSI PO BOX 850309 MOBILE AL 36685 IT SERVICES 149659 3 28261 2533832 10058 2572151 NET PATIENT REVENUE 621610 14820714 14820714 14820714 77178 77178 73053 0 73053 73053 73053 1943850 1635 1775092 0 168758 1635 170393 170393 10762 28261 17206 -6444 -6444 3377 0 3377 3377 JOINT VENTURE INCOME 900099 83213 83213 MISCELLANEOUS 900099 52524 52524 MEANINGFUL USE INCOME 900099 27327 27327 163064 17873486 14820714 0 480621 X 3074 3074 5000 5000 9900 9900 6881524 6397760 483764 249627 234628 14999 706586 639593 66993 447934 418929 29005 56831 56831 28934 28934 2617241 1872930 744311 10603 8849 1754 61968 46277 15691 244607 244607 40388 37299 3089 23893 20511 3382 127608 127608 800460 112314 688146 28175 28175 MEDICAL SUPPLIES 1466046 1460409 5637 OTHER EXPENSES 642109 483560 158549 BAD DEBT EXPENSE 285871 285871 MINNESOTA CARE TAX 82022 82022 14820401 12300545 2519856 0 1549279 3889852 1401359 2588308 3774731 2454605 4400 4899 300016 297018 223955 62637 9878037 1822012 7709264 8056025 1084523 2886796 171141 188974 16218668 20429114 413864 1159050 369231 338090 4148390 3906389 748498 1189096 5679983 6592625 X 10538685 13836489 10538685 13836489 16218668 20429114 3053085 244719 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 456 456 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. 4846337 663453 4182884 166337 4407 161930 3541099 1154152 2386947 1324264 1324264 8056025 THIRD PARTY PAYOR SETTLEMENTS 401126 DUE TO RELATED ORGANIZATIONS 787970 1189096 X 14817482 17206 17206 14800276 28934 3044276 3073210 17873486 14522802 17206 17206 14505596 28934 285871 314805 14820401 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: FUNDRAISING EVENT EXPENSES 17,206. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 217,002. PROVISION FOR BAD DEBTS 285,871. TRANSFER FROM RIDGEVIEW MEDICAL CENTER 2,533,832. CAPITAL CONTRIBUTIONS 7,571. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 17,206. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 285,871. FISH HOUSE RAFFLE 22170 11735 10435 10435 485 SPRING BENEFIT 16853 16526 327 327 300 2510 2000 1149 39023 28261 10762 10762 300 2510 2000 1634 17206 -6444 1 1 X 1 X 1 X 225.000000000000 1 1 0 0 255217 255217 0.01760 2565144 1386788 1178356 0.08110 2820361 1386788 1433573 0.09870 2 815 11070 11070 0.00080 1 3 87785 87785 0.00600 1 0 30 30 0.00000 4 818 98885 98885 0.00680 4 818 2919246 1386788 1532458 0.10550 54 3514 3514 0.00020 54 3514 3514 0.00020 1 285871 0 7609560 7726467 -116907 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 16 1 1 0 1 X WWW.RIDGEVIEWMEDICAL.ORG/ABOUT-US/ X 1 16 1 WWW.RIDGEVIEWMEDICAL.ORG/ABOUT-US/ 0 1 X 150.000000000000 225.000000000000 X X X X 1 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 X 1 X 0 X X X X 1 X 0 0 RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 5: PRIMARY DATA WAS COLLECTED THROUGH FOCUS GROUPS, COMMUNITY PERSPECTIVE SURVEY, AND A KEY INFORMANT SURVEY.FOCUS GROUPS WERE CONDUCTED TO ALLOW PARTICIPANTS TO PROVIDE INFORMATION ABOUT THEIR EXPERIENCES IN THE COMMUNITY AND AREAS IN WHICH THEY THOUGHT THE SERVICES AND RESOURCES PROVIDED COULD BE IMPROVED. THREE FOCUS GROUPS WERE HELD AND, IN TOTAL, 21 INDIVIDUALS PARTICIPATED TO DISCUSS AND IDENTIFY COMMUNITY HEALTH NEEDS RELATED TO SPECIFIC GEOGRAPHIC REGIONS. SEE APPENDIX B IN THE 2016 CHNA REPORT, AVAILABLE ONLINE, FOR A LIST OF BUSINESSES, ORGANIZATIONS AND AGENCIES THAT PARTICIPATED IN THE FOCUS GROUPS.SIBLEY MEDICAL CENTER CONDUCTED AN ONLINE SURVEY OF COMMUNITY RESIDENTS IN JUNE 2016. THE SURVEY INSTRUMENT WAS DEVELOPED TO GATHER INFORMATION FROM RESPONDENTS ABOUT THEIR PERCEPTIONS OF HEALTH CONCERNS IN THE COMMUNITY. THE ONLINE SURVEY WAS ISSUED TO RIDGEVIEW'S EMAIL DATABASE; RESPONSES WERE RECEIVED FROM 615 PARTICIPANTS, REPRESENTATIVE OF SIBLEY MEDICAL CENTER'S SERVICE AREA. IN ADDITION TO SURVEYING THE INDIVIDUAL PERSPECTIVE OF COMMUNITY MEMBERS, SIBLEY MEDICAL CENTER SURVEYED LEADERS IN THE COMMUNITY ON THEIR PERSPECTIVE OF THE BROADER COMMUNITY HEALTH NEEDS. THE INVITED COMMUNITY LEADERS PARTICIPATED THROUGH EITHER FOCUS GROUPS OR AN ONLINE SURVEY FOR KEY INFORMANTS. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 6A: THE 2016 COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED WITH RIDGEVIEW MEDICAL CENTER. 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, 2) AGING AND AGING-RELATED CONCERNS, 3) MENTAL AND BEHAVIORAL HEALTH, AND 4) ACCESS TO CARE. IN 2017, WE ENHANCED PROVIDER CARE TEAMS TO ACTIVELY FOCUS ON PATIENTS WITH DIABETES, ASTHMA AND VASCULAR DISEASE. RIDGEVIEW PROVIDED 1:1 AND GROUP DIABETIC AND OVERALL NUTRITION EDUCATION TO PATIENTS THROUGH DIABETIC EDUCATORS AND HEALTH RN NAVIGATORS. RIDGEVIEW IS ALSO A COMMITTEE MEMBER IN THE COMMUNITY ACT ON AHLZHEIMER'S TEAM. RIDGEVIEW IS ALSO PROVIDING AWARENESS ON COLORECTAL SCREENINGS BY ENHANCING PATIENT SCREENING OPTIONS AND EDUCATING COMMUNITIES THROUGH MARKETING CAMPAIGNS. SCHEDULE H, PART V, SECTION B: DURING 2017, SIBLEY MEDICAL CENTER DISCOVERED THAT IT HAD FAILED TO POST A PLAIN LANGUAGE SUMMARY OF ITS FINANCIAL ASSISTANCE POLICY ON ITS WEBSITE AND TO MAKE IT AVAILABLE TO PATIENTS. THE ORGANIZATION BELIEVES THAT THE FAILURE OCCURRED IN JANUARY, 2017. IT WAS DISCOVERED ON NOVEMBER 9, 2017 AND WAS RESOLVED BY NOVEMBER 30, 2017. THE FAILURE WAS CAUSED BY AN OVERSIGHT FROM THE STAFF THAT CREATED THE FINANCIAL ASSISTANCE POLICY AND APPLICATION.SIBLEY MEDICAL CENTER CORRECTED THE FAILURE BY CREATING A PLAIN LANGUAGE SUMMARY, POSTING IT ON OUR WEBSITE, AND MAKING IT OTHERWISE AVAILABLE TO PATIENTS AS REQUIRED UNDER SECTION 501(R) AND THE RELATED REGULATIONS. SIBLEY MEDICAL CENTER DID NOT IDENTIFY ANY PATIENTS OR OTHER INDIVIDUALS WHO WERE IMPACTED BY THE FAILURE. BECAUSE THE FINANCIAL ASSISTANCE POLICY AND APPLICATION WERE AVAILABLE AT ALL TIMES.WITH THE DEVELOPMENT OF THE PLAIN LANGUAGE SUMMARY, ITS REVIEW BECAME PART OF THE REGULAR ANNUAL REVIEW AND UPDATE OF THE FINANCIAL ASSISTANCE POLICY. SIBLEY MEDICAL CENTER USES A DOCUMENT MANAGEMENT SOFTWARE THAT REMINDS STAFF TO REVIEW AND UPDATE DOCUMENTS ON THEIR ESTABLISHED SCHEDULE. ALL DOCUMENTS RELATED TO THE FINANCIAL ASSISTANCE PROGRAM ARE SCHEDULED TO BE REVIEWED ANNUALLY. 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 150% OF FPG. 75% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 175% OF FPG. 50% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 200% OF FPG. AND 25% 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 $285,871 FOR THE YEAR ENDED DECEMBER 31, 2017. PART II, COMMUNITY BUILDING ACTIVITIES: SIBLEY MEDICAL CENTER PROVIDES "CAMPFIRE GONE WRONG", AN EMERGENCY PREPAREDNESS EXERCISE. 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 WITHOUTINSURANCE 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: THE NOTE OF SIBLEY MEDICAL CENTER'S 2017 FINANCIAL STATEMENTS THAT INCLUDES THE EXPLANATION OF BAD DEBT EXPENSE IS THE "PATIENT RECEIVABLES, NET" FOOTNOTE INCLUDED ON PAGE 7. PART III, LINE 8: SIBLEY MEDICAL CENTER USED THE 2017 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 $116,907 IN 2017. 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 RIDGEVIEW HEALTH IMPROVEMENT EFFORTS AND RESOURCES ARE ALIGNED WITH COMMUNITY HEALTH PRIORITIES.RIDGEVIEW 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 15,226 PEOPLE. SIBLEY COUNTY IS CONSIDERED A "FRINGE" COUNTY AND IS ON THE WESTERN BOUNDARY OF THE SEVEN-COUNTY TWIN CITIES METROPOLITAN AREA. THE DISTINCT QUALITIES OF EACH COMMUNITY PROVIDE A UNIQUE BLEND OF HISTORY AND CULTURE. MANY COMMUTERS 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 OF THE AGRICULTURAL PRODUCTS SOLD PER FARM IS $175,079. ALONG WITH THE PRODUCTION OF CROPS, A LARGE NUMBER OF FARMS RAISE LIVESTOCK, POULTRY, AND DAIRY CATTLE.ACCORDING TO THE 2010 US CENSUS, THERE ARE 15,226 PEOPLE LIVING IN SIBLEY COUNTY, WITH THE MAJORITY OF THE POPULATION RESIDING IN THE CITIES OF ARLINGTON, GAYLORD, AND WINTHROP. THE POPULATION BREAKDOWN SHOWS THOSE UNDER 18 YEARS OF AGE AT 27.7%, THOSE 65 YEARS AND OVER AT 16.4%; WITH THE MEDIAN RESIDENT AGE AT 40.0 YEARS. THE POPULATION DECREASED -0.9% SINCE 2010, BUT OVERALL THE POPULATION HAS STAYED 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, 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 MINNESOTA. RIDGEVIEW MEDICAL CENTER'S OTHER 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 IS CRITICAL ACCESS HOSPITAL IN ARLINGTON, MINNESOTA.CHASKA PLAZA SURGERY 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 LLC 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. 0 1 0 0 0 1 1 0 0 TODD SANDBERG RSMC ADMINISTRATOR 0 182519 0 23833 0 5352 0 8280 0 31857 0 251841 0 0 MICHAEL PHELPS PRESIDENT / CEO 0 368738 0 52130 0 1029599 0 10800 0 27054 0 1488321 0 0 ROBERT STEVENS PRESIDENT / CEO (THRU JUNE 2017) 0 443042 0 71627 0 1141791 0 10800 0 22026 0 1689286 0 0 GORDON GABLENZ CFO & CIO 0 303834 0 53085 0 307078 0 10800 0 35065 0 709862 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 ROBERT STEVENS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $1,143,151 WAS CONTRIBUTED TO THE PLAN, $19,816 ACCRUED WITHIN THE PLAN, AND $592,724 WAS PAID OUT OF THE PLAN. MICHEL PHELPS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $1,038,790 WAS CONTRIBUTED TO THE PLAN AND $500,177 WAS PAID OUT OF THE PLAN. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $315,740 WAS CONTRIBUTED TO THE PLAN, $7,874 ACCRUED WITHIN THE PLAN, AND $161,027 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. FORM 990, PART III, LINE 2 DURING 2017, RIDGEVIEW SIBLEY MEDICAL CENTER BEGAN OFFERING HOSPITALIST SERVICES TO INPATIENTS. 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 1,872,930. MANAGEMENT AND GENERAL EXPENSES 744,311. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,617,241. 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 3 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 CHASKA PLAZA SURGERY CENTER 3000 HUNDERTMARK RD CHASKA MN 55318 450975783 SURGERY SERVICES MN N/A 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 0 1 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0