2017-11-15T15:42:36-06:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-01-01 411801967 SIBLEY MEDICAL CENTER SIBL 5079642271 500 SOUTH MAPLE STREET WACONIA MN 553871791 GORDON GABLENZ CFO & CIO 5079642271 2017-11-15 1 ROBERT E SCHILE 6123764500 67.137.57.251 2017-11-15 10:00:07 PS P E5AEBE735E0DF1065458B6EBA0E7D1A366344C92 A0046212CE9672327E854F40E28815F016E88894 2016 2017-02-10 21:41:12Z RIDGEVIEW SIBLEY MEDICAL CENTER GORDON GABLENZ 500 SOUTH MAPLE STREET WACONIA MN 553871791 13688549 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. 9 9 115 5 0 0 26191 186536 13700648 13167701 29473 -32115 419195 276959 14175507 13599081 0 0 0 0 7622151 7561249 0 0 0 4477685 5114924 12099836 12676173 2075671 922908 15221395 16218668 5734387 5679983 9487008 10538685 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 10794823 0 13167701 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. 10794823 1 0 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 20 0 115 1 0 0 0 0 0 0 0 0 0 0 X 9 9 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 5079648424 601 WEST CHANDLER ARLINGTON MN 55307 KEVIN LINDSTRAND CHAIR 0.50 0.00 X X 1800 0 0 DENNIS SCHULTZ 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 1200 0 0 BRENDA PAUTSCH TRUSTEE 0.50 0.00 X 1200 5000 0 JIM PEDERSON TRUSTEE 0.50 0.00 X 1200 0 0 LYLE RUD TRUSTEE 0.50 0.00 X 1200 0 0 DEE THOMAS TRUSTEE 0.50 0.00 X 1200 0 0 DAVE WELCH TRUSTEE 0.50 0.00 X 1200 0 0 TODD SANDBERG RSMC ADMINISTRATOR 1.00 49.00 X 0 199446 20194 DARLA ANDERSON DIRECTOR OF FINANCE 1.00 49.00 X 0 91309 0 ROBERT STEVENS PRESIDENT / CEO 2.00 48.00 X 0 433264 23091 GORDON GABLENZ CFO & CIO 1.00 49.00 X 0 620943 25289 12600 1349962 68574 0 0 1 0 EMPAC 500 S MAPLE STREET WACONIA MN 55387 ED PHYSICIAN SERVICES 349508 MCKESSON TECHNOLOGIES INC 380 RUSSELL STREET HADLEY MA 01035 IT SERVICES 195056 PREMIER STAFFING INC 243 WINKLER TR COLOGNE MN 55322 NURSING SERVICES 183863 CPSI 660 WALL ST PO BOX 850309 MOBILE AL 36685 IT SERVICES 138679 ALLINA HEALTH SYSTEM NW 7710 PO BOX 9383 MINNEAPOLIS MN 55440 MEDICAL SERVICES 125203 5 186536 186536 NET PATIENT REVENUE 621610 13167701 13167701 13167701 42616 42616 70799 0 70799 70799 70799 74731 -74731 -74731 -74731 43684 14737 28947 28947 3268 0 3268 3268 MEANINGFUL USE INCOME 900099 70429 70429 JOINT VENTURE INCOME 900099 52602 52602 MISCELLANEOUS 900099 50914 50914 173945 13599081 13167701 0 244844 X 12600 12600 6318068 5949311 368757 222717 208715 14002 564577 529499 35078 443287 413386 29901 151 151 38752 38752 11212 11212 2038009 1639305 398704 25079 952 24127 81543 39527 42016 192830 192830 48697 43545 5152 28155 23463 4692 138050 138050 486340 110193 376147 20224 20224 MEDICAL SUPPLIES 1325366 1305127 20239 OTHER EXPENSES 183936 55896 128040 MINNESOTA CARE TAX 120645 120645 REPAIRS & MAINT 115828 98654 17174 260107 173208 86899 12676173 10794823 1881350 0 4161837 1549279 1194802 1401359 2136454 3774731 2926 4400 298370 300016 40187 223955 8729574 1020310 6002960 7709264 1213608 1084523 170251 171141 15221395 16218668 356371 783154 439660 369231 4384022 4148390 554334 379208 5734387 5679983 X 9487008 10538685 9487008 10538685 15221395 16218668 922908 128769 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 397 397 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 494345 4351992 166337 881 165456 3331072 525084 2805988 385828 385828 7709264 THIRD PARTY PAYOR SETTLEMENTS 379208 379208 X 13559471 58064 58064 13501407 11212 86462 97674 13599081 12593236 14737 14737 12578499 11212 86462 97674 12676173 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, NET 43,327. FUNDRAISING EVENT EXPENSES 14,737. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 86,462. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 14,737. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 86,462. FISH HOUSE RAFFLE 22730 22730 9963 456 SPRING BENEFIT 20954 20954 244 300 798 2237 739 43684 43684 10207 300 798 2237 1195 14737 28947 1 1 X 1 X 1 X 225.000000000000 1 1 0 0 131401 131401 0.01040 665064 336889 328175 0.02610 796465 336889 459576 0.03650 79 391687 391687 0.03110 79 391687 391687 0.03110 79 1188152 336889 851263 0.06760 1 86462 0 6718430 6857642 -139212 X 1 1 1 1 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.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT X 1 16 1 WWW.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT 0 1 X 150.000000000000 225.000000000000 X 0 1 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 AND WELLNESS, 2) OBESITY, 3) ACCESS TO CARE, AND 4) MENTAL HEALTH. 2015 AND 2016 QUALITY INITIATIVES FOCUSED ON UTILIZATION OF MENTAL HEALTH TOOLS IN OUR CLINICS TO ASSIST OUR PROVIDERS IN EARLIER DETECTION OF MENTAL HEALTH NEEDS IN OUR PATIENTS. IN 2016, WE INTRODUCED A NEW PARTNERSHIP IN BRINGING WELLNESS TO PATIENTS THROUGH EMPLOYER RELATIONSHIPS. IN 2016, WE ALSO CHANGED OUR EMR TO BE ONE AS A SYSTEM AND TO GIVE OUR PROVIDERS BETTER ACCESS TO PATIENT CHARTS AND VISITS ACROSS OUR ORGANIZATION. 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. 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 $86,462 FOR THE YEAR ENDED DECEMBER 31, 2016. 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 AND APPLICATION. PART III, LINE 4: THE NOTE OF SIBLEY MEDICAL CENTER'S 2016 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 2016 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 $139,212 IN 2016. 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: IN 2013, SIBLEY MEDICAL CENTER PARTNERED WITH NEIGHBORING COMMUNITIES, PUBLIC HEALTH DEPARTMENTS AND STRATIS HEALTH (AN INDEPENDENT, NONPROFIT ORGANIZATION THAT LEADS IN COLLABORATION AND INNOVATION IN HEALTH CARE QUALITY AND SAFETY) TO COMPLETE THE INITIAL DISCOVERY PHASE OF THE ASSESSMENT. THE LEAD CONSULTANT, KIM MCCOY WITH STRATIS HEALTH, FACILITATED THE INITIAL PHASE OF CONDUCTING A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT. THE OVERALL GOAL OF THE ASSESSMENT WAS TO IDENTIFY THE MAJOR HEALTH NEEDS, SERVICE GAPS, BARRIERS TO ACCESS, AND HEALTH PRIORITIES FOR THE COMMUNITY. AS PART OF THE ASSESSMENT, STRATUS HEALTH COLLECTED QUANTITATIVE AND QUALITATIVE INFORMATION FROM A BROAD ARRAY OF SOURCES. THE PURPOSE OF GATHERING THE INFORMATION AND STATISTICS WAS TO ANALYZE THE HEALTH OF THE COMMUNITY AND THEN FACILITATE THE DEVELOPMENT OF SHORT AND LONG-TERM PLANS TO GUIDE THE HEALTH INVESTMENTS OF SIBLEY COUNTY. PART VI, LINE 4: SIBLEY COUNTY INCLUDES SEVEN CITIES. IN AGGREGATE, THE LAND SIZE IS 600.41 SQUARE MILES WITH A TOTAL POPULATION OF 15,123 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 15,123 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 24.7%, THOSE 65 YEARS AND OVER AT 16.9%; WITH THE MEDIAN RESIDENT AGE AT 40.0 YEARS. THE POPULATION DECREASED -0.7% 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 A 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 178452 0 0 0 20994 0 7171 0 13023 0 219640 0 0 ROBERT STEVENS PRESIDENT / CEO 0 430374 0 0 0 2890 0 9873 0 13218 0 456355 0 0 GORDON GABLENZ CFO & CIO 0 300816 0 0 0 320127 0 10600 0 14689 0 646232 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 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 PART I, LINE 4B ROBERT STEVENS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER THAT ACCRUED $254,368 DURING 2015. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER THAT ACCRUED $506,054 DURING 2015. 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. 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 MEMBER. ANY DIRECTOR MAY ALSO BE REMOVED BY THE MEMBER. 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; (0) 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 A COPY OF THE FORM 990 TO THE BOARD OF DIRECTORS 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 POLICY. 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 ALL COMPENSATION 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 1,639,305. MANAGEMENT AND GENERAL EXPENSES 398,704. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,038,009. 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 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 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0