2016-11-08T12:27:03-06:00 2015-12-31 990 2015-01-01 581667166 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS INC MAYO 5075381297 1900 TEBEAU STREET WAYCROSS GA 31501 KEVIN M LOCKETT CFO 5075381297 2016-11-08 2015 2017-02-10 21:41:12Z ROGER FORGEY 1900 TEBEAU STREET WAYCROSS GA 31501 182803772 0 5983 X WWW.MAYOCLINICHEALTHSYSTEM.ORG X 1985 GA OPERATION OF A HOSPITAL, CLINICS, NURSING HOMES, A REHAB UNIT AND A SENIOR BEHAVIORAL UNIT. 9 4 1496 73 20925 0 2097771 1011104 174152185 180273400 60458 56420 923721 824133 177234135 182165057 164853 27342 0 0 85302483 96084701 0 0 0 106111809 107230521 191579145 203342564 -14345010 -21177507 114554521 161347067 51871151 119841204 62683370 41505863 X TO INSPIRE HOPE AND CONTRIBUTE TO HEALTH AND WELL-BEING BY PROVIDING THE BEST CARE TO EVERY PATIENT THROUGH INTEGRATED CLINICAL PRACTICE, EDUCATION, AND RESEARCH. 0 0 184933601 180736545 PATIENT CARE (SEE SCHEDULE O):MAYO CLINIC HEALTH SYSTEM IN WAYCROSS (MCHS-WAYCROSS) IS PART OF THE MAYO CLINIC HEALTH SYSTEM. MAYO CLINIC HEALTH SYSTEM IS A FAMILY OF CLINICS, HOSPITALS AND HEALTH CARE FACILITIES SERVING COMMUNITIES IN MINNESOTA, IOWA, WISCONSIN AND GEORGIA. AS PART OF MAYO CLINIC, THE HEALTH SYSTEM OFFERS CARE DESIGNED FOR THE WHOLE BODY CLOSE TO THE PATIENT'S HOME, WHEN THEY NEED IT. A MULTIDISCIPLINARY TEAM OF EXPERTS HAS READY ACCESS TO KNOWLEDGE, RESOURCES, AND EXPERTISE OF MAYO CLINIC AND COLLABORATES ON PROVIDING EXACTLY THE CARE THE PATIENT NEEDS. MAYO CLINIC HEALTH SYSTEM SITES EMPLOY APPROXIMATELY 1,000 PHYSICIANS AND 15,000 ALLIED HEALTH STAFF. IN ADDITION, MAYO CLINIC PHYSICIANS FROM MULTIPLE SPECIALTIES REGULARLY SEE PATIENTS AT HEALTH SYSTEM FACILITIES. BESIDES HAVING HEALTH CARE FACILITIES IN MORE THAN 60 COMMUNITIES, MAYO CLINIC HEALTH SYSTEM INCLUDES 19 OWNED HOSPITALS, TWO OWNED NURSING HOMES, PHYSICIAN SERVICE AGREEMENTS WITH ONE ADDITIONAL HOSPITAL, AND CONTRACT MANAGEMENT AGREEMENTS WITH TWO ADDITIONAL HOSPITALS AND ONE NURSING HOME. SINCE ITS INCEPTION IN 1992, MAYO CLINIC HEALTH SYSTEM HAS GROWN INTO ONE OF THE MOST SUCCESSFUL REGIONAL HEALTH CARE SYSTEMS IN THE UNITED STATES. MORE THAN 600,000 UNIQUE PATIENTS ACCOUNT FOR MORE THAN 2.6 MILLION VISITS ANNUALLY IN MAYO CLINIC HEALTH SYSTEM. IT IS ALSO A NATIONAL LEADER IN QUALITY AND SAFETY EFFORTS. AS PART OF THE MAYO CLINIC HEALTH SYSTEM, MCHS-WAYCROSS SERVES A NINE-COUNTY REGION IN SOUTHEAST GEORGIA. MCHS-WAYCROSS OPERATES A 231-BED HOSPITAL, A 96-BED SKILLED NURSING FACILITY, A REHAB UNIT AND A PSYCHIATRIC UNIT IN WAYCROSS, GEORGIA ALONG WITH AN ADDITIONAL 78-BED SKILLED NURSING FACILITY IN BLACKSHEAR, GEORGIA. MCHS-WAYCROSS PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS FINANCIAL ASSISTANCE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. SERVICES ARE ALSO PROVIDED TO MEDICAID AND MEDICARE PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES.FINANCIAL ASSISTANCE (AT COST) PROVIDED TO PATIENTS IN 2015 WAS APPROXIMATELY $5,187,700. THE COST OF UNCOMPENSATED CARE PROVIDED TO LOW INCOME PATIENTS THROUGH MEDICAID WAS APPROXIMATELY $10,428,700. THE COST OF UNCOMPENSATED CARE PROVIDED TO PATIENTS THROUGH MEDICARE WAS APPROXIMATELY $16,906,800. SATILLA ADVOCACY SERVICES, A RAPE CRISIS AND CHILD ADVOCACY CENTER, OPERATES UNDER THE UMBRELLA OF MCHS-WAYCROSS AND SERVES VICTIMS OF SEXUAL ASSAULT AND OTHER VIOLENT CRIMES IN THE SIX COUNTIES THAT MAKE UP THE WARE JUDICIAL CIRCUIT. A FULL RANGE OF SERVICES IS OFFERED FROM THE TIME A VICTIM REPORTS AN INCIDENT, INCLUDING EMERGENCY DEPARTMENT SERVICES, FOLLOW UP AT THE RAPE CRISIS/CHILD ADVOCACY CENTER, THERAPY AND SUPPORT BY OUR LEGAL ADVOCACY PERSONNEL. IN 2015, SATILLA ADVOCACY SERVED 603 NEW VICTIMS AND PRESENTED PREVENTION EDUCATION TO 13,688 PEOPLE.ALL REVENUE AFTER EXPENSES IS REINVESTED TO CARE FOR THE CITIZENS OF THE COMMUNITY THROUGH CLINICAL CARE, HEALTH PROGRAMS, STATE-OF-THE-ART TECHNOLOGY AND FACILITIES, AND TEACHING AND TRAINING OF MEDICAL PROFESSIONALS.APPROXIMATELY 73 COMMUNITY VOLUNTEERS PROVIDED APPROXIMATELY 9,617 HOURS OF DONATED TIME TO THE HOSPITAL IN 2015. VOLUNTEERS PROVIDE HOSPITALITY SERVICES TO PATIENTS, FAMILIES AND VISITORS. THE DONATED SERVICES PROVIDED BY THE VOLUNTEERS IN 2015 WERE VALUED AT APPROXIMATELY $226,580 BASED ON STATISTICS FROM THE INDEPENDENT SECTOR. 1203800 27342 195317 COMMUNITY PROGRAMS & HEALTH PROFESSIONS EDUCATION (SEE SCHEDULE O):CONSISTENT WITH ITS CHARITABLE MISSION, MCHS-WAYCROSS PROVIDES COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES. FOR 2015, MCHS-WAYCROSS PROVIDED HEALTH EDUCATION AND HEALTH SUPPORT SERVICES. MANY OF THESE BENEFITS AND SERVICES ARE DESCRIBED BELOW.MCHS-WAYCROSS IS INVOLVED IN MANY ACTIVITIES AIMED AT EDUCATING THE COMMUNITY ABOUT HEALTH-RELATED TOPICS. EXAMPLES OF THESE ACTIVITIES INCLUDE A MONTHLY CALENDAR OF EVENTS AND CLASSES OFFERED AT THE HOSPITAL THAT IS DISTRIBUTED VIA EMAIL AND ADVERTISED IN LOCAL NEWSPAPERS. THE FOLLOWING ARE SOME OF THE CLASSES AND SEMINARS OFFERED DURING 2015. - SENIOR SAFETY DAY - PRENATAL CLASSES - DIABETES CLASSES - SMOKING CESSATION - WOMEN'S HEALTH BLITZ - CANCER SUPPORT GROUPTHE HOSPITAL STAFF PROVIDED BLOOD PRESSURE SCREENINGS, EDUCATIONAL PROGRAMS AND HEALTH SEMINARS TO RESIDENTS IN SCHOOLS, SENIOR CITIZENS CENTERS, SOCIAL CLUBS AND AT HEALTH FAIRS THROUGHOUT THE SERVICE AREA INCLUDING SENIOR SAFETY DAY, SWAMPFEST, AND PIERCE, BRANTLEY AND WARE COUNTY HIGH SCHOOL FOOTBALL GAMES. MCHS-WAYCROSS PROVIDED APPROXIMATELY $22,000 OF STAFF TIME AND SUPPLIES TO HELP PATIENTS ACCESS FREE MEDICATIONS THROUGH PHARMACEUTICAL COMPANIES' PRESCRIPTION ASSISTANCE PROGRAMS. MCHS-WAYCROSS OFFERED ENROLLMENT ASSISTANCE TO 339 PEOPLE IN THE COMMUNITY SO THEY WOULD BE ABLE TO ACCESS PUBLIC HEALTH PROGRAMS SUCH AS MEDICAID. IN 2015, MCHS-WAYCROSS WORKED WITH LOCAL COLLEGES AND TECHNICAL SCHOOLS TO OFFER CLINICAL ROTATIONS FOR A VARIETY OF HEALTHCARE PROFESSIONALS THAT INCLUDED PROVIDING A CLINICAL SETTING FOR STUDENTS THAT INCLUDED SIX HOURS PER STUDENT OF STAFF MENTORING. ORIENTATION, DRUG SCREENS, CRIMINAL BACKGROUND CHECKS AND SOCIAL SECURITY CHECKS WERE PROVIDED FOR ALL STUDENTS. IN ADDITION, RENT-FREE CLASSROOM SPACE WAS PROVIDED. MCHS-WAYCROSS PARTNERS WITH THE MEDICAL COLLEGE OF GEORGIA AT GEORGIA REGENTS UNIVERSITY TO SPONSOR A RESIDENCY PROGRAM. THIS PROGRAM SERVES AS A RESPONSE TO DECLINING NUMBERS OF PRIMARY CARE PHYSICIANS IN RURAL SOUTH GEORGIA COMMUNITIES AND THE REGION AND A DESIRE TO TRAIN PRIMARY CARE PHYSICIANS IN SETTINGS THAT WOULD FACILITATE THE CHOICE OF PRACTICE IN SMALL AND RURAL COMMUNITIES.IN 2015, CONTRIBUTIONS WERE MADE TO COMMUNITY PARTNERSHIP EVENTS SUCH AS THE AMERICAN CANCER SOCIETY, YMCA, OKEFENOKEE TECHNICAL COLLEGE FOUNDATION AND THE SOUTHEAST CANCER UNIT.AS A CORPORATE CITIZEN, MCHS-WAYCROSS TAKES A LEADERSHIP ROLE AND COLLABORATES WITH OTHER REGIONAL AGENCIES TO INSURE THE COMMUNITY IS PREPARED FOR DISASTER SHOULD IT STRIKE. IN 2015, MCHS-WAYCROSS PROVIDED OVER $83,000 OF SUPPORT TO REGIONAL EMERGENCY PREPAREDNESS. 186137401 1 1 0 1 0 0 0 0 1 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 117 0 1 1496 1 1 1 0 0 0 0 0 0 0 0 0 X 9 4 1 1 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 GA X CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 CALAMIA MD KENNETH T DIRECTOR/PRESIDENT/CEO 1.00 40.00 X X 0 409587 72647 CATCHINGS MD TIMOTHY T DIRECTOR 40.00 0.00 X 879449 0 67023 DAWSON MD NANCY L DIRECTOR/VICE PRESIDENT 1.00 40.00 X X 0 294890 68177 DYE MD JAMES W DIRECTOR 1.00 0.00 X 0 0 0 HERRIN OWEN DIRECTOR 1.00 0.00 X 0 0 0 HOFFMAN MARY J DIRECTOR/SECRETARY/TREASURER/CAO 1.00 40.00 X X 0 366692 55266 MUSIC ZA DIRECTOR 1.00 0.00 X 0 0 0 PRESUTTI DO RICHARD J DIRECTOR/PRESIDENT/CEO 1.00 40.00 X X 0 460216 54328 SWEAT HOLLI H DIRECTOR/ASSISTANT SECRETARY 40.00 0.00 X X 190401 0 53791 WATERS MD DONALD DIRECTOR 1.00 0.00 X 0 0 0 BEARD TERESA B ASSISTANT SECRETARY 1.00 40.00 X 0 111389 33191 LOCKETT KEVIN M INTERIM CFO 1.00 40.00 X 0 165792 47001 RATHBUN JON CFO 1.00 40.00 X 0 172561 18240 COCHON MD ARISTOTLE P PHYSICIAN 40.00 0.00 X 408314 0 52335 JHA MD ASIT K PHYSICIAN 40.00 0.00 X 760450 0 55932 LOTT MD MCGREGOR N PHYSICIAN 40.00 0.00 X 676694 0 56240 WYKSTRA MD DAVID J PHYSICIAN 40.00 0.00 X 591241 0 53897 BORDERS MD YOLANDA M PHYSICIAN 40.00 0.00 X 690898 0 48674 GRIFFIN MD HOWARD PHYSICIAN 40.00 0.00 X 672537 0 8734 JOHNSON MD KENNETH A PHYSICIAN 40.00 0.00 X 639878 0 68191 PILLAI MD DILIP P PHYSICIAN 40.00 0.00 X 720837 0 67659 SINGLETON MD BRIAN A PHYSICIAN 40.00 0.00 X 648885 0 51705 CROFT CHERYL R FORMER OFFICER 0.00 40.00 X 0 243699 57954 LANGE MD STEPHEN M FORMER OFFICER 0.00 40.00 X 0 606363 57915 SMITH JR WINDELL R FORMER OFFICER 0.00 40.00 X 0 198104 54380 WALTERS ROBERT M FORMER OFFICER 0.00 40.00 X 0 321723 73101 BAKER MD MICHAEL P FORMER KEY EMPLOYEE 40.00 0.00 X 265602 0 66604 7145186 3351016 1242985 79 1 1 0 SODEXO INC 9801 WASHINGTON BLVD GAITHERABURY MD 20878 FOOD SERVICES 4687413 SOUTHEAST GEORGIA ANESTHESIA LLC 1900 TEBEAU STREET WAYCROSS GA 31501 ANESTHESIA SERVICES 2140586 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 MEDICAL & SUPPORT SERVICES 1145544 DIAGNOSTIC PET LLC 1256 SHILOH ROAD ELLAVILLE GA 31806 PET SCANS 1101842 CERNER HEALTHCARE SOLUTIONS INC 2800 ROCKCREEK PKWY NORTH KANSAS CITY MO 64117 BILLING SERVICES 1062406 32 2656 89973 848385 70090 1011104 NET PATIENT REVENUE 620000 180078083 180057158 20925 EDUCATION REVENUE 611600 195317 195317 180273400 431540 431540 165877 41095 124782 124782 124782 222500 597620 -375120 -375120 -375120 VENDING/CAFETERIA 722210 630377 630377 MISC. REVENUE 900099 68974 28085 40889 699351 182165057 180910937 20925 222091 X 27342 27342 3845768 3845768 1302257 1212493 89764 65139113 58386526 6752587 7077741 6344033 733708 14001229 12549804 1451425 4718593 4229444 489149 377779 377779 41622 41622 686 686 26881737 24144000 2737737 263301 52278 211023 9735235 6167694 3567541 102311 1741 100570 2517116 2293396 223720 540165 416477 123688 1786 1786 7928948 7691528 237420 258857 237210 21647 UNRELATED BUSINESS TAXE 167 167 BAD DEBT EXPENSE 28585438 28585438 MEDICAL SUPPLIES 27848011 27848011 MEDICAID SURCHARGE 1661407 1661407 485955 401189 84766 203342564 186137401 17205163 0 87818 236728 580841 0 36117364 33870024 55084 30546 246600 126216 3057772 2909978 36532 188922 147647610 84153989 64179799 63493621 435621 44746960 4362664 4281064 5394426 11463008 114554521 161347067 25039029 28719615 8964 5122 654689 0 22685 44253 26145784 91072214 51871151 119841204 X 62605118 41466869 78252 38994 62683370 41505863 114554521 161347067 -21177507 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 30265 0 1 19122 49387 0 PART II-B, LINE 1: DURING 2015, MCHS-WAYCROSS OR ITS CONSULTANTS HAD CONTACT WITH STATE GOVERNMENT OFFICIALS AND/OR THEIR STAFF TO DISCUSS VARIOUS HEALTH CARE RELATED ISSUES. THE AMOUNT IN "OTHER ACTIVITIES" REPRESENTS A PORTION OF PROFESSIONAL DUES ATTRIBUTABLE TO LOBBYING. 0 1 X 1263459 1263459 41095 83580436 42350815 41270716 2825402 1188564 1636838 58393657 40614610 17779047 1543561 1543561 63493621 MAYO POOLED INVESTMENTS 44746960 F 44746960 DUE FROM AFFILIATES 9501255 DEFERRED COMPENSATION 420524 OTHER LONG TERM ASSETS 1541229 11463008 DUE TO AFFILIATES 90651690 DEFERRED COMPENSATION 420524 91072214 X PART IV, LINE 2B: NURSING HOME RESIDENT TRUST ACCOUNT - RESIDENTS' FUNDS. PART X, LINE 2: AT DECEMBER 31, 2015 AND 2014, THE RESERVE FOR UNRECOGNIZED TAX BENEFITS WAS NOT SIGNIFICANT, AND AS A RESULT, THERE IS NO RESERVE FOR UNRECOGNIZED TAX BENEFITS RECORDED FOR THE FILING ORGANIZATION. PART X, OTHER LIABILITIES (DUE TO AFFILIATES): THE DUE TO AMOUNT IS CURRENTLY CONTESTED BY THE WAYCROSS COMMUNITY DIRECTORS. MAYO CLINIC HAS INDICATED A WILLINGNESS TO NEGOTIATE THE BALANCE DUE IN THE CONTEXT OF A NEW AFFILIATION AND EXIT TRANSACTION THAT POSITIONS WAYCROSS FOR FUTURE SUCCESS. PART X, OTHER LIABILITIES (DUE TO AFFILIATES): RECLASS OF NET RESERVES BETWEEN 2014 AND 2015. AT 12/31/14, $45,225,000 OF NET RESERVES WERE CARRIED AS AN OFFSET TO INTERCOMPANY LIABILITIES (INCLUDED ON FORM 990, PART X, LINE 25). IN 2015, THE NET RESERVES WERE SET UP IN AN INVESTMENT ACCOUNT (MAYO POOLED INVESTMENTS REFLECTED ON FORM 990, PART X, LINE 12) WITH A CORRESPONDING OFFSET TO INTERCOMPANY LIABILITIES (INCLUDED ON FORM 990, PART X, LINE 25). 1 1 X 1 X 1 X 1 0 0 5187711 5187711 0.02970 33423690 22995038 10428652 0.05970 38611401 22995038 15616363 0.08940 255247 255247 0.00150 759209 145976 613233 0.00350 18685985 5878961 12807024 0.07330 18716 18716 0.00010 19719157 6024937 13694220 0.07840 58330558 29019975 29310583 0.16780 1430 1430 0.00000 67986 67986 0.00040 92126 92126 0.00050 2630 2630 0.00000 6456 6456 0.00000 170628 170628 0.00090 0 28585438 40451911 40397476 54435 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS 1900 TEBEAU STREET WAYCROSS GA 31501 148-416 X X X MAYO CLINIC HEALTH SYSTEM IN WAYCROSS 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.MAYOCLINICHEALTHSYSTEM.ORG/ABOUT-US X 1 13 0 1 0 1 X 200.000000000000 400.000000000000 X X X X X X X 1 1 X X X X 1 X MAYOCLINICHEALTHSYSTEM.ORG X MAYOCLINICHEALTHSYSTEM.ORG X MAYOCLINICHEALTHSYSTEM.ORG X X X X X X 1 X 0 X X X X X 1 X 0 0 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 5: PRIMARY DATA COLLECTION METHODS INCLUDED INTERVIEWS AND FOCUS GROUPS WITH KEY COMMUNITY REPRESENTATIVES. THE PURPOSE OF THE INTERVIEWS AND FOCUS GROUPS WAS TO GAIN DIRECT INPUT REGARDING HEALTH NEEDS, INCLUDING PRIMARY AND CHRONIC DISEASE NEEDS AND HEALTH ISSUES ASSOCIATED WITH UNINSURED PERSONS, LOW INCOME PERSONS AND MINORITY GROUPS.IN ADDITION, COMMUNITY INPUT WAS GARNERED FROM THE COMMUNITY ADVISORY COMMITTEE, WHICH INCLUDED REPRESENTATIVES FROM THE WARE COUNTY HEALTH DEPARTMENT, THE WARE COUNTY CHILDREN'S INITIATIVE AND OTHER COMMUNITY ORGANIZATIONS. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 11: TO ADDRESS THE NEEDS OF THE COMMUNITY'S TOBACCO USAGE AND OBESITY, MAYO CLINIC HEALTH SYSTEM IN WAYCROSS (MCHS-WAYCROSS) ALONG WITH WARE AND PIERCE COUNTY SCHOOL SYSTEMS HAVE PARTNERED TOGETHER TO HELP LOCAL COMMUNITY SCHOOLS. MCHS-WAYCROSS UTILIZED THE PARTNERSHIP WITH THE SCHOOLS (MEMORIAL DRIVE AND BLACKSHEAR ELEMENTARY), AS A COLLABORATIVE EFFORT, BY ENGAGING IN EDUCATION PROGRAMS ABOUT OBESITY AND TOBACCO AS PART OF A SOLUTION TO EDUCATE YOUTH ON THE IMPORTANCE OF HEALTHY EATING AND LIFESTYLES. MCHS-WAYCROSS' RESPIRATORY DEPARTMENT OFFERS EDUCATION ON SMOKING AND GENERAL TOBACCO USE AS AN ONGOING PUBLIC EDUCATION PROGRAM OFFERED TO ALL RESPIRATORY PATIENTS AND THEIR FAMILIES REGARDLESS OF A REPORTED INCIDENCE OF SMOKING. ALL PATIENTS ARE PRESENTED WITH A DISCHARGE PACKET REGARDING THE USE OF TOBACCO AND SMOKING. MCHS-WAYCROSS CONTINUES TO PARTNER WITH THE YMCA IN SUPPORT OF CAMP REVEILLE, A CAMP FOR UNDERSERVED CHILDREN, TO PROMOTE HEALTHY EATING AND EXERCISE.IN 2015, MCHS-WAYCROSS PARTNERED WITH SOUTHEAST GEORGIA PEDIATRICS AND AGSOUTH CREDIT UNION TO HOST A FARM-TO-LUNCH FOR THE STUDENTS AT MEMORIAL DRIVE ELEMENTARY. THIS WAS AN EFFORT TO JOIN THE NATION IN CELEBRATING FARM-TO-SCHOOL MONTH IN OCTOBER AND WAS USED TO EXPOSE THE CHILDREN TO LOCAL, FRESH REAL FOOD AND TO HELP SUPPORT LOCAL FARMERS. MCHS-WAYCROSS SPONSORED SCHOOL IN THE COMMUNITY, ON WEDNESDAY, OCTOBER 7TH, 2015. MCHS-WAYCROSS REPRESENTATIVES, DR. JOHN PRESUTTI AND TONI NELSON, ATTENDED THE LUNCH THAT DAY AND HAD PHOTOGRAPHS TAKEN WITH THE KIDS ENJOYING A LOCAL BURGER, LOCAL LETTUCE/SALAD AND SOME FRESH LOCAL BLUEBERRY JUICE.TO ADDRESS THE ADULT POPULATION, MCHS-WAYCROSS REACHED OUT TO COMMUNITY MEMBERS AND COMMUNITY ORGANIZATIONS THROUGH THE USE OF EDUCATIONAL TALKS, LECTURES, AND PRESENTATIONS ON HEALTH ISSUES CONDUCTED BY PHYSICIANS AND CLINICAL STAFF.PHYSICIAN PRESENTATIONS TO THE COMMUNITY: - WAYCROSS ROTARY - DR. LIBERTIN - KIWANIS CLUB - DR. PURI - WAYCROSS ROTARY CLUB - DR. CAMSARI - ST. PETER'S BAPTIST CHURCH - DR. CATCHINGS - GREEN THUMB GARDEN CLUB - DR. REESE - BLACKSHEAR ROTARY CLUB - DR. COCHON - WAYCROSS ROTARY -DR. COCHON - SENIOR WEIR CENTER, DOUGLAS- DR. CALAMIA - WAYCROSS EXCHANGE CLUB - DR. PURI - KIWANIS CLUB - ANGIE MOODY - BLACKSHEAR ROTARY - DR. HUFF - WAYCROSS ROTARY - DR. HUFF - WAYCROSS WOMEN'S CLUB - DR. PRESUTTI - WAYCROSS RETIRED TEACHERS ASSOCIATION - DR. REESE - TRINITY METHODIST KINGAGERS - DR. REESE - WAYCROSS KIWANIS CLUB - TERRY ANDERSONTO ADDRESS ACCESS TO HEALTH CARE, MCHS-WAYCROSS IS VERY LIMITED IN WHAT IT IS CAPABLE OF DOING. NEW PHYSICIANS AND PHYSICIAN ASSISTANTS HAVE BEEN RECRUITED. TRANSPORTATION FOR THE CITIZENS OF WARE AND PIERCE COUNTY IS PROVIDED BY A LOCAL BUSINESS GROUP. THESE SERVICES TAKE THE ELDERLY AND UNDERSERVED CITIZENS TO DOCTOR APPOINTMENTS AND OTHER FUNCTIONS AS NEEDED.HOW MCHS-WAYCROSS SERVES ITS COMMUNITY: - FINANCIAL ASSISTANCE - UNREIMBURSED COSTS OF GOVERNMENT PROGRAMS - COMMUNITY HEALTH IMPROVEMENT - HEALTH PROFESSIONS EDUCATION - SUBSIDIZED HEALTH CARE - CASH/IN-KIND SUPPORT - COMMUNITY BUILDINGTO HELP BETTER SERVE THE NEEDS IN THE COMMUNITY, MCHS-WAYCROSS PLANS TO INCREASE ITS FOCUS ON TOBACCO CESSATION. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 13B: IF A PATIENT BALANCE EXCEEDS 25% OF THE ANNUAL HOUSEHOLD INCOME, BUT THE PATIENT DOES NOT QUALIFY BASED ON FPG, CHARITY WILL BE ADJUSTED TO A MINIMUM OF THE AMOUNT GENERALLY BILLED (AGB). THE AGB IS DETERMINED USING THE LOOK-BACK METHOD AND CALCULATED USING ALL CLAIMS ALLOWED BY PRIVATE PAY INSURERS (INCLUDING MEDICARE ADVANTAGE) AND MEDICARE (TRADITIONAL) FOR INPATIENT AND OUTPATIENT SERVICES FOR THE YEAR. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 13H: THE REGIONAL PROXIMITY OF A PATIENT'S RESIDENCY IS A FACTOR FOR PRESCHEDULED SERVICES ONLY AND SECONDARY TO MEDICAL NEED. REGIONAL PROXIMITY IS NOT A FACTOR FOR EMERGENCY CARE PROVIDED. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 15E: REFER PATIENT TO APPLY FOR MEDICAL ASSISTANCE. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 16I: WITH REGARD TO THE POSTINGS WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE ARE DISCUSSED WITH THE PATIENT. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 20E: FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE TO EVERY PATIENT VIA MAYO'S PUBLIC WEBSITE, FROM CUSTOMER SERVICE AND PATIENT ACCESS LOCATIONS, AND IS REFERENCED ON MAYO'S AUTHORIZATION FORMS AND STATEMENTS. IN ADDITION, SIGNS ARE POSTED IN THE ADMISSIONS AREA AND THE PROCESS OF HOW TO APPLY IS AVAILABLE ON THE MAYO CLINIC WEBSITE.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, MAYO DISCUSSES ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE.MONTHLY STATEMENTS ARE SENT TO PATIENTS THAT OUTLINE CURRENT CHARGES AND ACTIONS WITH INSURANCE AND INCLUDES INFORMATION ABOUT MAYO'S CHARITY CARE POLICY. SOME MAYO SITES UTILIZE ADVOCATES TO CONTACT THE PATIENT UPON DISCHARGE TO HELP THEM SECURE GOVERNMENTAL ASSISTANCE OR FINANCIAL ASSISTANCE.EACH CHARITY CARE REVIEW IS DOCUMENTED IN MAYO'S BILLING SYSTEM AND COMMUNICATED TO THE PATIENT. COMPLETED CHARITY CARE FORMS ARE MAINTAINED EITHER IN PAPER OR ELECTRONIC FORMAT. THE PATIENT IS INFORMED REGARDING THE OUTCOME OF THE REVIEW.MAYO OFTEN IDENTIFIES CHARITY CARE OPPORTUNITIES AFTER THE PATIENT HAS BEEN DISMISSED. IN MANY CASES, THIS IS DUE TO LIMITED INSURANCE COVERAGE OR INSURANCE DENIALS AFTER THE SERVICE WAS PERFORMED. IN THESE CASES, WHEN A PATIENT EXPRESSES AN INABILITY TO PAY FOR THEIR SERVICES, STAFF WILL INITIATE A CHARITY REVIEW AS INDICATED BY THE FINANCIAL ASSISTANCE POLICY, WHICH IS AVAILABLE FOR EVERY PATIENT AT MAYOCLINIC.ORG. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 22D: THE POLICY ALLOWS FOR A MINIMUM DISCOUNT OF 70% TO ELIGIBLE INDIVIDUALS WHICH RESULTS IN AN AMOUNT LESS THAN USING THE AVERAGE OF THE THREE BEST NEGOTIATED COMMERCIAL RATES OR THE BEST NEGOTIATED COMMERCIAL RATE. 23 1 - SATILLA CARE CENTER 1600 RIVERSIDE AVENUE WAYCROSS GA 31501 SKILLED NURSING FACILITY 2 - PIERCE COUNTY NURSING HOME 221 EAST CARTER AVENUE BLACKSHEAR GA 31516 SKILLED NURSING FACILITY 3 - SATILLA REGIONAL REHAB INSTITUTE 2500 SATILLA PARKWAY WAYCROSS GA 31501 REHAB UNIT 4 - SENIOR BEHAVIORAL UNIT 1900 TEBEAU STREET WAYCROSS GA 31501 PSYCHIATRIC UNIT / BEHAVIORAL HEALTH 5 - MCHSW - FAMILY PSYCHIATRY 1707 CITY BOULEVARD SQUARE WAYCROSS GA 31501 PSYCHIATRY CLINIC 6 - MCHSW - NEUROLOGY 2101 TEBEAU STREET WAYCROSS GA 31501 NEUROLOGY CLINIC 7 - MCHSW - PULMONOLOGY 2005 PIONEER STREET WAYCROSS GA 31501 PULMONOLOGY CLINIC 8 - MCHSW - SURGICAL ASSOCIATES 1908 ALICE STREET WAYCROSS GA 31501 SURGICAL OFFICE 9 - MCHSW - ORTHOPEDICS 305 PINEVIEW DRIVE WAYCROSS GA 31501 ORTHOPEDICS CLINIC 10 - MCHSW - OPHTHALMOLOGY 413 LISTER STREET WAYCROSS GA 31501 OPTHALMOLOGY CLINIC 11 - MCHSW - CARDIOLOGY 2004 PIONEER STREET WAYCROSS GA 31501 CARDIOLOGY CLINIC 12 - MCHSW - INFECTIOUS DISEASES 411 LISTER STREET WAYCROSS GA 31501 INFECTIOUS DISEASES CLINIC 13 - MCHSW - OBGYN 505 CITY BLVD WAYCROSS GA 31501 OB/GYN CLINIC 14 - MCHSW - FAMILY MEDICINE 1921 ALICE STREET WAYCROSS GA 31501 FAMILY MEDICINE CLINIC 15 - MCHSW - EXPRESS CARE 1921 ALICE STREET WAYCROSS GA 31501 CONVENIENT CARE CLINIC 16 - MCHSW - HEMATOLOGYONCOLOGY 1706 ALICE STREET WAYCROSS GA 31501 HEMATOLOGY/ONCOLOGY CLINIC 17 - MCHSW - RADIATION ONCOLOGY 1451 CHURCH STREET WAYCROSS GA 31501 RADIATION ONCOLOGY CLINIC 18 - MCHSW - HEMATOLOGYONCOLOGY - DOUGLAS SHIRLEY AVENUE SUITES XXX-XX-XXXX DOUGLAS GA 31535 HEMATOLOGY/ONCOLOGY CLINIC 19 - MCHSW - OUTREACH CLINIC 396 KINGSLAND DRIVE FOLKSTON GA 31537 OUTREACH CLINIC 20 - MCSHW - FAMILY MEDICINE 808 BEACON STREET WAYCROSS GA 31501 PRIMARY CARE CLINIC 21 - MCSHW - HEMATOLOGYONCOLOGY 1206 ALICE STREET WAYCROSS GA 31501 HEMATOLOGY/ONCOLOGY CLINIC 22 - MCHSW - HEMATOLOGYONCOLOGY 101 SEYMOUR ST DOUGLAS GA 31533 HEMATOLOGY/ONCOLOGY CLINIC 23 - MCHSW - OUTPATIENT IMAGING CENTER 410 ZACHARY STREET WAYCROSS GA 31501 RADIOLOGY/IMAGING PART I, LINE 3C: MEDICAL INDIGENCY MAY BE USED TO DETERMINE ELIGIBILITY. IF A PATIENT BALANCE EXCEEDS 25% OF THE ANNUAL HOUSEHOLD INCOME, BUT THE PATIENT DOES NOT QUALIFY BASED ON FPG, CHARITY WILL BE ADJUSTED TO A MINIMUM OF THE AMOUNT GENERALLY BILLED (AGB). THE AGB IS DETERMINED USING THE LOOK-BACK METHOD AND CALCULATED USING ALL CLAIMS ALLOWED BY PRIVATE PAY INSURERS (INCLUDING MEDICARE ADVANTAGE) AND MEDICARE (TRADITIONAL) FOR INPATIENT AND OUTPATIENT SERVICES FOR THE YEAR. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A-7C (FINANCIAL ASSISTANCE, MEDICAID SHORTFALL, AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS).THE AMOUNTS FOR LINES 7E-7I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND WOULD NOT BE BASED ON A COST-TO-CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING NET COMMUNITY BENEFIT COST ATTRIBUTED TO A PHYSICIAN CLINIC WAS INCLUDED AS SUBSIDIZED HEALTH SERVICES: $1,958,116. 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 $ 28,585,438. SCHEDULE H, PART I, LINE 5 THE FILING ORGANIZATION ESTIMATES CHARITY CARE FOR FINANCIAL PLANNING PURPOSES ONLY. THE ESTIMATED AMOUNT OF CHARITY CARE DOES NOT INFLUENCE OR HAVE ANY IMPACT ON THE AMOUNT OF CHARITY CARE PROVIDED. PART II, COMMUNITY BUILDING ACTIVITIES: THROUGH IN-KIND DONATIONS AND GRANTS TO PUBLIC, PRIVATE AND NONPROFIT ORGANIZATIONS, THE FILING ORGANIZATION ASSISTS WITH SUSTAINING AND ENHANCING THE COMMUNITIES IT SERVES BY ASSISTING IN COMMUNITY SUPPORT, ENVIRONMENTAL IMPROVEMENTS AND COMMUNITY IMPROVEMENT ADVOCACY. PART III, LINE 2: PART III, SECTION A, LINE 1:THE FILING ORGANIZATION REPORTS BAD DEBT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15 IS FOLLOWED TO THE EXTENT THAT IT ALIGNS WITH THE GUIDELINES SET FORTH BY GAAP.METHODOLOGY FOR SCHEDULE H, PART III, LINE 2:BAD DEBT EXPENSE IS DETERMINED BASED ON GAAP AND IS EXPLAINED IN THE ACCOUNTS RECEIVABLE FOOTNOTE OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART III, LINE 4: FOOTNOTES RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS CAN BE FOUND ON PAGES 5, 7, 8 AND 9 OF MAYO CLINIC'S 2015 CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SURPLUS REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT (USING A MEDICARE COST REPORT STEP-DOWN METHODOLOGY). HOWEVER, USING A FINANCIAL STATEMENT COST-TO-CHARGE RATIO METHODOLOGY ACTUALLY RESULTS IN A MEDICARE SHORTFALL OF $16,906,800 AS REPORTED IN THE CORE FORM, PART III, PROGRAM SERVICE ACCOMPLISHMENTS.THE MOST COMMON REASONS FOR A DIFFERENCE BETWEEN THE MEDICARE SURPLUS REPORTED ON SCHEDULE H AND THE MEDICARE SHORTFALL REPORTED ON THE CORE FORM, PART III INCLUDE: (1) INCLUSION OF MEDICARE ADVANTAGE REVENUE AND EXPENSES; (2) INCLUSION OF PART B REVENUE AND EXPENSES; (3) INCLUSION OF OTHER FEE SCHEDULE REVENUE; AND (4) SOME TIMING ISSUES.REASONS WHY MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT ARE: (1) ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; (2) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; (3) THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS; AND (4) THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: MAYO CLINIC AND ITS AFFILIATES STRIVE TO ASSIST ALL PATIENTS IN MEETING THEIR FINANCIAL OBLIGATION PRIOR TO ENLISTING THE ASSISTANCE OF A COLLECTION AGENCY BY MAKING REASONABLE ATTEMPTS TO COLLECT FROM INSURANCE COMPANIES AND OTHER THIRD-PARTY PAYORS. IN ADDITION, MAYO CLINIC AND ITS AFFILIATES ACCEPT REASONABLE PAYMENT PLANS FROM PATIENTS WHEN AN ACCOUNT IS THE PATIENT'S RESPONSIBILITY AND TRY TO IDENTIFY THOSE PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. FINANCIAL ASSISTANCE IS OFFERED TO ANY PATIENT IF THE FACTS AND CIRCUMSTANCES SUGGEST THAT THE PATIENT DOES NOT HAVE THE ABILITY TO PAY THEIR BILL IN WHOLE OR IN PART. IN THE EVENT THAT AN ACCOUNT IS REFERRED TO A COLLECTION AGENCY, GUIDELINES ARE FOLLOWED; INCLUDING SUSPENDING ALL COLLECTION ACTIVITY IF A FINANCIAL ASSISTANCE APPLICATION HAS BEEN SUBMITTED AFTER THE ACCOUNT HAS BEEN REFERRED FOR COLLECTION. IF A COLLECTION AGENCY IDENTIFIES A PATIENT AS POTENTIALLY MEETING MAYO CLINIC'S FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA OR THE PATIENT ASKS TO APPLY FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY IS SUSPENDED UNTIL MAYO REVIEWS THE ACCOUNT FOR FINANCIAL ASSISTANCE ELIGIBILITY BASED ON SUBMISSION OF REQUESTED INFORMATION. COLLECTION ACTIVITY WOULD ONLY RESUME IF THE PATIENT IS DETERMINED TO BE INELIGIBLE FOR FINANCIAL ASSISTANCE OR IS ELIGIBLE FOR ONLY PARTIAL FINANCIAL ASSISTANCE AND DOES NOT AGREE TO PAY THE REMAINING BALANCE. PART VI, LINE 2: CONSISTENT WITH ITS CHARITABLE MISSION, MAYO CLINIC HEALTH SYSTEM IN WAYCROSS (MCHS-WAYCROSS) PROVIDES COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES. A COMMUNITY BENEFIT IS A PLANNED, MANAGED, ORGANIZED, AND MEASURED APPROACH TO MEETING IDENTIFIED COMMUNITY HEALTH NEEDS. IT INVOLVES THE PARTICIPATION OF THE HEALTHCARE ORGANIZATION WORKING WITH THE COMMUNITY TO BENEFIT ITS RESIDENTS THROUGH PROGRAMS AND SERVICES THAT IMPROVE THEIR HEALTH STATUS AND QUALITY OF LIFE. MCHS-WAYCROSS IMPROVES THE HEALTH AND WELL BEING OF THE NINE-COUNTY SERVICE AREA IN SOUTHEAST GEORGIA THAT IT SERVES THROUGH CLINICAL SERVICES, EDUCATION, AND PARTNERSHIPS THAT BUILD HEALTH CAPACITY IN THE COMMUNITY. COMMUNITY BENEFITS ARE PROVIDED FOR ALL CITIZENS AS WELL AS FOR THE MEDICALLY UNDERSERVED. THE ORGANIZATION PAYS CLOSE ATTENTION TO THE NEEDS OF LOW INCOME AND OTHER VULNERABLE PERSONS AND THE COMMUNITY AT LARGE. THE HOSPITAL WORKS WITH COMMUNITY GROUPS TO IDENTIFY NEEDS STRENGTHEN EXISTING COMMUNITY PROGRAMS AND PLAN NEWLY NEEDED SERVICES. IT PROVIDES A WIDE ARRAY OF COMMUNITY BENEFIT SERVICES DESIGNED TO IMPROVE COMMUNITY HEALTH AND THE HEALTH OF INDIVIDUALS. MCHS-WAYCROSS WORKS TO INCREASE ACCESS TO HEALTH CARE, IN ADDITION TO PROVIDING FREE AND DISCOUNTED SERVICES TO PEOPLE WHO ARE UNINSURED AND UNDERINSURED. THE ORGANIZATION'S COMMUNITY BENEFIT PROGRAMS ARE DESIGNED TO RESPOND TO ASSESSED NEEDS AND ARE FOCUSED ON PREVENTION AND EDUCATION. PART VI, LINE 3: MEASURES TO PUBLICIZE FINANCIAL ASSISTANCE POLICY:MAYO CLINIC IS COMMITTED TO OFFERING FINANCIAL ASSISTANCE TO ELIGIBLE PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY FOR THEIR MEDICAL SERVICES IN WHOLE OR IN PART. IN ORDER TO ACCOMPLISH THIS CHARITABLE GOAL, MAYO CLINIC AND MAYO CLINIC HEALTH SYSTEM SITES WIDELY PUBLICIZE THIS POLICY IN THE COMMUNITIES THAT THE INDIVIDUAL MAYO CLINIC AFFILIATED SITES SERVE. MAYO CLINIC AFFILIATED SITES MAKE COPIES OF THIS POLICY AND APPLICATIONS AVAILABLE BY POSTING IT ON THEIR WEBPAGE INCLUDING THE ABILITY TO DOWNLOAD A COPY OF THE POLICY AND APPLICATION FREE OF CHARGE. INDIVIDUALS IN THE COMMUNITY SERVED WILL BE ABLE TO OBTAIN A COPY OF THE POLICY IN LOCATIONS THROUGHOUT EACH MAYO CLINIC AFFILIATED SITE OR UPON REQUEST. THE POLICY EXPLAINS THE FINANCIAL ASSISTANCE PROGRAM AND FACTORS AFFECTING ELIGIBILITY. WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED. ADDITIONALLY, CHARITABLE CARE AND FINANCIAL ASSISTANCE IS REFERENCED ON PATIENT CORRESPONDENCE INCLUDING: THE MONTHLY STATEMENT OF ACCOUNT, ACCOUNT BALANCE LETTERS, AND LATE PAYMENT NOTIFICATIONS. ALL PATIENT CORRESPONDENCE REFERENCING CHARITABLE CARE AND FINANCIAL ASSISTANCE INCLUDE INTERNET, PHONE, AND MAILING ADDRESS CONTACT INFORMATION. PART VI, LINE 4: MCHS-WAYCROSS SERVES A NINE-COUNTY REGION IN SOUTHEAST GEORGIA. THE MAIN CAMPUS IS LOCATED IN WAYCROSS, GEORGIA (WARE COUNTY) AND INCLUDES A HOSPITAL, A SKILLED NURSING FACILITY, A REHAB UNIT AND A PSYCHIATRIC UNIT. AN ADDITIONAL SKILLED NURSING FACILITY IS LOCATED IN BLACKSHEAR, GEORGIA (PIERCE COUNTY).ACCORDING TO THE UNITED STATES CENSUS BUREAU, THE 2015 POPULATION ESTIMATE FOR WARE COUNTY (WHICH COMPRISES MOST OF WAYCROSS'S SERVICE AREA) IS 35,370. THE CENSUS BUREAU REPORTS THAT 23.9% OF THE POPULATION IS UNDER 18 YEARS OLD AND 16.5% IS 65 YEARS OLD OR OLDER. AN ESTIMATED 28.8% OF INDIVIDUALS ARE LIVING BELOW THE POVERTY LEVEL. PART VI, LINE 5: THE FILING ORGANIZATION IS AN AFFILIATE OF THE MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES ARE LARGE, MULTI-FACETED, INTEGRATED, NOT-FOR-PROFIT GROUP PRACTICES AND HEALTH SYSTEMS. AT MAYO CLINIC, DOCTORS FROM EVERY MEDICAL SPECIALTY WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF "THE NEEDS OF THE PATIENT COME FIRST." THE ORGANIZATIONS (INCLUDING HOSPITAL AND NON-HOSPITAL ENTITIES) WORK TOGETHER TO SERVE THEIR COMMUNITIES AT THE LOCAL, REGIONAL, NATIONAL AND GLOBAL LEVELS. THIS COMMUNITY BENEFIT HAPPENS THROUGH ITS FOCUS ON PATIENT CARE, EDUCATION, AND RESEARCH. SPECIFICALLY, THE TAX-EXEMPT PURPOSE OF MAYO CLINIC AND ITS AFFILIATES IS THREE-FOLD:PRACTICE - PRACTICE MEDICINE AS AN INTEGRATED TEAM OF COMPASSIONATE, MULTI-DISCIPLINARY PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS WHO ARE FOCUSED ON THE NEEDS OF PATIENTS FROM OUR COMMUNITIES, REGIONS, THE NATION AND THE WORLD.EDUCATION - EDUCATE PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS AND BE A DEPENDABLE SOURCE OF HEALTH INFORMATION FOR OUR PATIENTS AND THE PUBLIC.RESEARCH - CONDUCT BASIC AND CLINICAL RESEARCH PROGRAMS TO IMPROVE PATIENT CARE AND TO BENEFIT SOCIETY, INCLUDING PARTNERING WITH MAYO HEALTH SYSTEM PRACTICES TO PERFORM PRACTICE-BASED RESEARCH DESIGNED TO IMPROVE PATIENT CARE.THROUGH ITS MISSION, MAYO CLINIC AND ITS AFFILIATES ENRICH THE COMMUNITIES IN WHICH THEY OPERATE AS WELL AS THE BROADER COMMUNITY - IMPROVING MEDICINE THROUGH RESEARCH, EDUCATING PHYSICIANS AND OTHER HEALTH CARE PROVIDERS, AND PROVIDING CARE AND SUPPORT TO PEOPLE IN NEED. PLEASE REFER TO THE PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, FOR FURTHER DESCRIPTION OF THE FILING ORGANIZATION'S ACTIVITIES.SURPLUS FUNDS - MAYO CLINIC AND ITS AFFILIATES REINVEST THEIR NET OPERATING INCOME TO ADVANCE MEDICAL RESEARCH AND TEACH THE NEXT GENERATION OF HEALTH CARE PROFESSIONALS, AS WELL AS TO ALLOW THE INDIVIDUAL ENTITY TO SUSTAIN ITS MISSION AND PREPARE FOR THE FUTURE. COMMUNITY REPRESENTATION ON GOVERNING BODY - THE BOARD OF TRUSTEES IS THE GOVERNING BODY OF MAYO CLINIC. A MAJORITY OF ITS MEMBERS ARE EXTERNAL, INDEPENDENT TRUSTEES. IT HAS OVERALL RESPONSIBILITY FOR THE CHARITABLE, CLINICAL PRACTICE, SCIENTIFIC AND EDUCATIONAL MISSION AND PURPOSES OF MAYO CLINIC AND ITS AFFILIATES AS SET FORTH IN ITS ARTICLES OF INCORPORATION AND BYLAWS. BECAUSE OF MAYO CLINIC'S NATIONAL PRESENCE, THESE TRUSTEES ARE SELECTED BASED ON THEIR AREAS OF EXPERTISE, WHETHER IN HEALTH CARE POLICY, BUSINESS, GOVERNMENT OR ANOTHER FIELD. IN ADDITION TO THIS COMMUNITY REPRESENTATION AT THE PARENT ENTITY, THE FILING ORGANIZATION ALSO INVOLVES LOCAL COMMUNITY MEMBERS ON ITS GOVERNING BODY. OPEN VS. CLOSED STAFF MODEL - THE FILING ORGANIZATION'S STAFF PRIVILEGES ARE GENERALLY EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY.EMERGENCY ROOM - THE FILING ORGANIZATION MAINTAINS AN EMERGENCY ROOM 24 HOURS A DAY, 7 DAYS A WEEK, WHICH IS OPEN TO ALL WITHOUT REGARD TO THE ABILITY TO PAY. PART VI, LINE 6: THIS ORGANIZATION IS A PART OF MAYO CLINIC HEALTH SYSTEM (WHICH IS PART OF A LARGER GROUP OF ENTITIES AFFILIATED WITH MAYO CLINIC). THE MAYO CLINIC HEALTH SYSTEM IS DESCRIBED IN RESPONSE TO CORE FORM, PART III, STATEMENT OF PROGRAM ACCOMPLISHMENTS, LINE 4A (REPORTED IN SCHEDULE O). THAT STATEMENT ALSO DESCRIBES THE ROLES OF THE VARIOUS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED. PART VI, LINE 7 NEITHER THE FILING ORGANIZATION, NOR ANY RELATED ORGANIZATION, FILES A COMMUNITY BENEFIT REPORT WITH ANY STATE OTHER THAN THE EXTENT TO WHICH COMMUNITY BENEFIT INFORMATION IS INCLUDED IN OTHER REPORTING REQUIREMENTS SUCH AS INFORMATION PROVIDED TO A STATE HOSPITAL ASSOCIATION. X X 1 1 1 1 0 0 0 0 0 0 0 CALAMIA MD KENNETH T DIRECTOR/PRESIDENT/CEO 0 370831 0 0 0 38756 0 56562 0 16085 0 482234 0 0 CATCHINGS MD TIMOTHY T DIRECTOR 830450 0 0 0 48999 0 55646 0 11377 0 946472 0 0 0 DAWSON MD NANCY L DIRECTOR/VICE PRESIDENT 0 285989 0 0 0 8901 0 53360 0 14817 0 363067 0 0 HOFFMAN MARY J DIRECTOR/SECRETARY/TREASURER/CAO 0 345161 0 0 0 21531 0 34373 0 20893 0 421958 0 0 PRESUTTI DO RICHARD J DIRECTOR/PRESIDENT/CEO 0 415681 0 0 0 44535 0 32848 0 21480 0 514544 0 0 SWEAT HOLLI H DIRECTOR/ASSISTANT SECRETARY 190114 0 0 0 287 0 31846 0 21945 0 244192 0 0 0 LOCKETT KEVIN M INTERIM CFO 0 165129 0 0 0 663 0 20360 0 26641 0 212793 0 0 RATHBUN JON CFO 0 95980 0 0 0 76581 0 8612 0 9628 0 190801 0 0 COCHON MD ARISTOTLE P PHYSICIAN 401990 0 0 0 6324 0 27065 0 25270 0 460649 0 0 0 JHA MD ASIT K PHYSICIAN 736463 0 0 0 23987 0 35220 0 20712 0 816382 0 0 0 LOTT MD MCGREGOR N PHYSICIAN 658177 0 0 0 18517 0 30964 0 25276 0 732934 0 0 0 WYKSTRA MD DAVID J PHYSICIAN 573644 0 0 0 17597 0 30964 0 22933 0 645138 0 0 0 BORDERS MD YOLANDA M PHYSICIAN 650494 0 0 0 40404 0 27251 0 21423 0 739572 0 0 0 GRIFFIN MD HOWARD PHYSICIAN 646526 0 0 0 26011 0 5300 0 3434 0 681271 0 0 0 JOHNSON MD KENNETH A PHYSICIAN 637847 0 0 0 2031 0 48567 0 19624 0 708069 0 0 0 PILLAI MD DILIP P PHYSICIAN 682616 0 0 0 38221 0 44802 0 22857 0 788496 0 0 0 SINGLETON MD BRIAN A PHYSICIAN 644300 0 0 0 4585 0 33455 0 18250 0 700590 0 0 0 CROFT CHERYL R FORMER OFFICER 0 242163 0 0 0 1536 0 41303 0 16651 0 301653 0 0 LANGE MD STEPHEN M FORMER OFFICER 0 518151 0 0 0 88212 0 33930 0 23985 0 664278 0 0 SMITH JR WINDELL R FORMER OFFICER 0 197200 0 0 0 904 0 29158 0 25222 0 252484 0 0 WALTERS ROBERT M FORMER OFFICER 0 305907 0 0 0 15816 0 56223 0 16878 0 394824 0 0 BAKER MD MICHAEL P FORMER KEY EMPLOYEE 236278 0 0 0 29324 0 46890 0 19714 0 332206 0 0 0 PART I, LINE 1A MICHAEL P. BAKER, M.D. RECEIVED LOAN FORGIVENESS WHICH WAS TREATED AS TAXABLE INCOME AND WAS GROSSED UP. HOUSING ALLOWANCES ARE PROVIDED WHEN JUSTIFIED BY BUSINESS NEED SUCH AS RELOCATION OR WORK ASSIGNMENT. IN 2015, DILIP P. PILLAI, M.D. RECEIVED A HOUSING ALLOWANCE THAT WAS TREATED AS TAXABLE INCOME AND WAS GROSSED UP. BRIAN A. SINGLETON, M.D. RECEIVED A HOUSING ALLOWANCE THAT WAS TREATED AS TAXABLE INCOME. PART I, LINE 3 THE FILING ORGANIZATION RELIED ON A RELATED ORGANIZATION FOR ESTABLISHING THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. SEE CORE 990 PART VI SECTION B LINE 15 FOR FURTHER INFORMATION REGARDING THE PROCESS UTILIZED. PART I, LINES 4A-B PURSUANT TO A SEPARATION AGREEMENT, JON RATHBUN, FORMER CHIEF FINANCIAL OFFICER OF MAYO CLINIC FLORIDA / MAYO CLINIC JACKSONVILLE, RECEIVED THE FOLLOWING BENEFITS: PURCHASE OF HIS HOME AT APPRAISED FAIR MARKET VALUE, CASH COMPENSATION OF $65,757 (AN AMOUNT EQUAL TO 3 MONTHS' SALARY AND COBRA BENEFITS), AND AN AGREEMENT TO FORGO COLLECTION OF ANY RELOCATION OR MOVING EXPENSES THAT WERE SUBJECT TO POTENTIAL REPAYMENT ABSENT RETENTION. THIS ENTITY OR ITS AFFILIATE HAS A SUPPLEMENTAL RETIREMENT PLAN (SRP) DESIGNED TO ROUGHLY APPROXIMATE AN EXTENSION OF THE BENEFITS UNDER THE MAYO PENSION PLAN TO INCOME ABOVE THE INTERNAL REVENUE CODE QUALIFIED PLAN LIMIT IN SECTION 401(A)(17). STARTING JANUARY 1, 2011, ALL SRP BENEFITS ARE PAID AS AN ANNUAL TAXABLE CASH PAYMENT. THE FOLLOWING INDIVIDUALS RECEIVED A PAYMENT FROM THE SUPPLEMENTAL RETIREMENT PLAN. AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III). CALAMIA M.D., KENNETH T. $30,734 DAWSON M.D., NANCY L. $ 2,918 HOFFMAN, MARY J. $18,685 LANGE M.D., STEPHEN M. $70,388 PRESUTTI D.O., RICHARD J. $ 9,125 WALTERS, ROBERT M. $11,890 THIS ENTITY HAS A SUPPLEMENTAL RETIREMENT PLAN (SRP) DESIGNED TO ROUGHLY APPROXIMATE AN EXTENSION OF THE BENEFITS UNDER THE ENTITY'S 403(B) PLAN TO INCOME ABOVE THE INTERNAL REVENUE CODE QUALIFIED PLAN LIMIT IN SECTION 401(A)(17). THE FOLLOWING INDIVIDUALS RECEIVED A PAYMENT FROM THE SUPPLEMENTAL RETIREMENT PLAN. AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III). BORDERS M.D., YOLANDA M. $20,100 CATCHINGS M.D., TIMOTHY T. $43,948 COCHON M.D., ARISTOTLE P. $6,163 GRIFFIN M.D., HOWARD $11,361 JHA M.D., ASIT K. $23,521 LOTT M.D., MCGREGOR N. $18,212 PILLAI M.D., DILIP P. $18,185 WYKSTRA M.D., DAVID J. $17,362 PART II: COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. MICHAEL P BAKER MD FORMER KEY EMPLOYEE SIGN-ON BONUS SET-UP AS A FORGIVABLE LOAN X 205000 30546 0 0 1 30546 FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUAL(S) IS/ARE EMPLOYED BY A RELATED ORGANIZATION: LOCKETT, KEVIN M. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL(S) WHO IS/ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: RATHBUN, JON, THE FOLLOWING INDIVIDUAL(S) IS/ARE EMPLOYED BY A RELATED ORGANIZATION: CALAMIA M.D., KENNETH T., BEARD, TERESA B., PRESUTTI D.O., RICHARD J., HOFFMAN, MARY J., DAWSON M.D., NANCY L., RATHBUN, JON RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL(S) WHO IS/ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: PRESUTTI D.O., RICHARD J., HOFFMAN, MARY J., DAWSON M.D., NANCY L., RATHBUN, JON, LOCKETT, KEVIN M. FORM 990, PART VI, SECTION A, LINE 3 MAYO CLINIC, MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH, AND OTHER RELATED COMPANIES PROVIDE MANAGEMENT SERVICES TO THE ENTIRE SYSTEM OF ENTITIES. SINCE THE ENTITIES ARE RELATED ORGANIZATIONS, COMPENSATION FOR THE OFFICERS, DIRECTORS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES HAS BEEN DISCLOSED IN PART VII AND SCHEDULE J AS REQUIRED. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THIS CORPORATION SHALL BE MAYO CLINIC JACKSONVILLE (A NONPROFIT CORPORATION). FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER APPOINTS MEMBERS TO THE BOARD OF DIRECTORS THROUGH MULTIPLE PROCESSES AS SPECIFIED IN THE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE ARTICLES AND BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, DEBT, AMENDMENT OF THE ARTICLES AND BYLAWS AND GENERAL OPERATION DECISIONS. THE COMMUNITY DIRECTORS HAVE THE AUTHORITY TO ENFORCE CERTAIN PROVISIONS OF THE INTEGRATION AGREEMENT. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY MAYO CORPORATE TAX WITH ASSISTANCE FROM SITE ACCOUNTING STAFF. THE TAX RETURN GOES THROUGH TWO LEVELS OF REVIEW WITHIN THE CORPORATE TAX UNIT. IT IS THEN REVIEWED BY THE CHIEF ADMINISTRATIVE OFFICER AND FINANCE STAFF. A COPY OF THE FORM 990 IS THEN PROVIDED TO EACH MEMBER OF THE FILING ORGANIZATION'S GOVERNING BODY VIA US MAIL, E-MAIL, OR DISTRIBUTION AT A BOARD MEETING. ALL QUESTIONS ARE ADDRESSED PRIOR TO FILING THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C MAYO CLINIC AND ITS AFFILIATES HAVE A COMPREHENSIVE CONFLICT OF INTEREST POLICY APPLICABLE TO ALL OF THE AFFILIATED ENTITIES AND TO ALL DIRECTORS, OFFICERS, AND EMPLOYEES OF THOSE ENTITIES. ALL CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES WHO WE ANTICIPATE WILL BE LISTED ON A FORM 990 ARE ASKED TO COMPLETE AN "ANNUAL TAX AND COMPLIANCE DISCLOSURE" FORM. THIS INFORMATION IS REVIEWED BY BOTH THE CORPORATE TAX DEPARTMENT AND THE OFFICE OF CONFLICT OF INTEREST REVIEW. ALL DISCLOSURES OF CURRENT OR PROPOSED ACTIVITY THAT REQUIRE ACTION UNDER THE POLICY ARE THE SUBJECT OF ONGOING REVIEW AND ACTION THROUGH THE OFFICE OF CONFLICT OF INTEREST REVIEW AND THE CONFLICT OF INTEREST REVIEW BOARD. INVOLVED INDIVIDUALS ARE INFORMED OF ALL REQUIRED ACTION. MANY TYPES OF RELATIONSHIPS THAT COULD CREATE CONFLICTS OF INTEREST ARE PROHIBITED. OTHER TYPES OF RELATIONSHIPS ARE PERMITTED SUBJECT TO COMPLIANCE WITH THE MANAGEMENT PLAN ESTABLISHED BY THE CONFLICT OF INTEREST REVIEW BOARD. A COMMON MANAGEMENT STRATEGY FOR PERMITTED ACTIVITIES IS TO REQUIRE BILATERAL RECUSAL AND APPROPRIATE DOCUMENTATION IN THE MINUTES OF MAYO CLINIC (AND/OR AFFILIATE) AND THE OUTSIDE ENTITY. ADDITIONAL CONFLICT OF INTEREST POLICIES AND PROCEDURES EXIST FOR CERTAIN ENTITIES CONCERNING RESEARCH CONTRACTS AND OTHER TYPES OF POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 THE FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES HAVE A COORDINATED PROCESS FOR REVIEWING AND APPROVING COMPENSATION AND BENEFITS FOR PHYSICIANS, EXECUTIVE AND SENIOR ADMINISTRATIVE LEADERSHIP, ALONG WITH ALLIED HEALTH STAFF. IN ADDITION TO ANY REVIEW AND APPROVAL THAT MAY TAKE PLACE AT THE LOCAL ENTITY OR REGIONAL LEVEL, THE FOLLOWING INDEPENDENT APPROVAL PROCESS OCCURS ANNUALLY PRIOR TO IMPLEMENTATION OF THE RESPECTIVE COMPENSATION INCREASE. THE COMPENSATION AND BENEFIT PROGRAM OF THE CHIEF EXECUTIVE OFFICER (CEO) WAS REVIEWED AND APPROVED BY THE PROCESS DESCRIBED BELOW FOR PHYSICIANS OF THE ARIZONA, FLORIDA, AND ROCHESTER, MINNESOTA CAMPUSES. THE MAYO CLINIC SALARY AND BENEFITS COMMITTEE INITIALLY REVIEWS THE COMPENSATION AND BENEFIT PROGRAMS FOR PHYSICIANS OF THE ARIZONA, FLORIDA, AND ROCHESTER, MINNESOTA CAMPUSES. THE COMMITTEE IS COMPRISED OF MAYO EMPLOYEES, BUT IS INDEPENDENT FOR INTERNAL REVENUE CODE 4958 FOR THE INDIVIDUALS WHOSE SALARIES ARE REVIEWED (WITH RECUSAL WHERE APPROPRIATE). THE MAYO CLINIC SALARY AND BENEFITS COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. FOLLOWING REVIEW BY THE MAYO CLINIC SALARY AND BENEFITS COMMITTEE, THE COMPENSATION AND BENEFIT PROGRAMS FOR PHYSICIANS OF THE ARIZONA, FLORIDA, AND ROCHESTER, MINNESOTA CAMPUSES ARE REVIEWED AND APPROVED BY THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE. THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE IS COMPRISED OF NINE OF THE EXTERNAL INDEPENDENT MEMBERS OF THE MAYO CLINIC BOARD OF TRUSTEES. THIS GROUP REVIEWS AND APPROVES THE COMPENSATION AND BENEFIT PROGRAMS FOR PHYSICIANS FROM ALL CAMPUSES, AS WELL AS CERTAIN SENIOR ADMINISTRATIVE AND EXECUTIVE LEADERSHIP (INCLUDING ALL PERSONS BELIEVED TO BE DISQUALIFIED PERSONS). THIS PROCESS ESTABLISHES ACCEPTABLE RANGES FOR VARIOUS POSITIONS, LEVELS, AND SPECIALTIES. THE COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. THE SALARY AND BENEFIT PROGRAM OF THE CHIEF ADMINISTRATIVE OFFICER (CAO) WAS REVIEWED AND APPROVED BY THE PROCESS DESCRIBED BELOW FOR SENIOR ADMINISTRATIVE LEADERSHIP. THE COMPENSATION AND BENEFIT PROGRAMS FOR SENIOR ADMINISTRATIVE LEADERSHIP FOR ALL CAMPUSES, INCLUDING THE MAYO CLINIC HEALTH SYSTEM LOCATIONS, ARE REVIEWED AND APPROVED BY THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE. THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE IS COMPRISED OF NINE OF THE EXTERNAL INDEPENDENT MEMBERS OF THE MAYO CLINIC BOARD OF TRUSTEES. THIS GROUP REVIEWS AND APPROVES THE COMPENSATION AND BENEFIT PROGRAMS FOR PHYSICIANS FROM ALL CAMPUSES, AS WELL AS CERTAIN SENIOR ADMINISTRATIVE AND EXECUTIVE LEADERSHIP (INCLUDING ALL PERSONS BELIEVED TO BE DISQUALIFIED PERSONS). THIS PROCESS ESTABLISHES ACCEPTABLE RANGES FOR VARIOUS POSITIONS, LEVELS, AND SPECIALTIES. THE COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE FILING ORGANIZATION'S GOVERNING DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST AND ALSO ON THE MAYOCLINIC.ORG WEBSITE. THE FILING ORGANIZATION IS A HOSPITAL AFFILIATED WITH MAYO CLINIC. AS SUCH, MAYO CLINIC'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO THE FILING ORGANIZATION'S FORM 990 AND WOULD BE AVAILABLE UPON REQUEST OF THE FORM 990. FORM 990, PART IX, LINE 11G I/C PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,105,838. MANAGEMENT AND GENERAL EXPENSES 107,589. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,213,427. OTHER PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 22,038,162. MANAGEMENT AND GENERAL EXPENSES 2,630,148. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,668,310. FORM 990, PART XII, LINE 2B: INDIVIDUAL AUDIT STATEMENTS ARE BEING PREPARED FOR THE FILING ORGANIZATION BUT WERE NOT FINALIZED AS OF THE FILING OF THIS RETURN. FILING OF CERTAIN FOREIGN FORMS DISCLOSURE STATEMENT RELATED TO FORMS 5713: FORM 5713 HAS BEEN FILED BY THE FOLLOWING MEMBERS OF THE CONTROLLED GROUP: MAYO CLINIC (EIN: 41-6011702) MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH (EIN: 41-1506440) DISCLOSURE STATEMENT RELATED TO FORMS 5471: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 4 AND 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCS). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. TAXPAYER NAME: MAYO CLINIC ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 5471 WAS FILED: 41-6011702 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED TAXPAYER NAME: MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 5471 WAS FILED: 41-1506440 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED DISCLOSURE STATEMENT RELATED TO FORMS 8865: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 8865, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN PARTNERSHIPS, AS A CATEGORY 2 AND 3 FILER. THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 8865 FOR THESE PARTNERSHIPS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. TAXPAYER NAME: MAYO CLINIC ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 8865 WAS FILED: 41-6011702 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED CHARTERHOUSE INC 200 FIRST STREET SW ROCHESTER MN 55905 411405254 RETIREMENT LIVING CENTER MN 501(C)(3) 9 MAYO CLINIC 1 DESTINATION MEDICAL CENTER EDA 50 SOUTH SIXTH STREET SUITE 1500 MINNEAPOLIS MN 554021498 464893585 ECONOMIC DEVELOPMENT MN 501(C)(3) 11-I MAYO CLINIC 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(C)(3) 9 MFMER 1 LUTHER LAKESIDE APARTMENTS INC PO BOX 1510 EAU CLAIRE WI 54702 391409024 LOW INCOME HOUSING FOR ELDERLY WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - CLINIC MN 501(C)(3) 9 N/A 1 MAYO CLINIC ARIZONA 13400 EAST SHEA BOULEVARD SCOTTSDALE AZ 85259 860800150 HOSPITAL AND CLINIC AZ 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC FLORIDA (A NONPROFIT CORPORATION) 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 590714831 HOSPITAL FL 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MAYO CLINIC HOSPITAL -- ROCHESTER 200 FIRST STREET SW ROCHESTER MN 55905 410944601 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC JACKSONVILLE 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 593337028 PATIENT CARE - CLINIC FL 501(C)(3) 7 MAYO CLINIC 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 200 FIRST STREET SW ROCHESTER MN 55905 411506440 CHARITABLE, EDUCATIONAL & SCIENTIFIC ACTIVITIES MN 501(C)(3) 9 MAYO CLINIC 1 MAYO CLINIC STIFTUNG 60486 FRANKFURT AM MAIN FRANKFURT GM FUNDRAISING FOUNDATION GM MFMER 1 MCHS IN WAYCROSS INC 1900 TEBEAU STREET WAYCROSS GA 31501 581667166 HOSPITAL GA 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MCHS--ALBERT LEA AND AUSTIN 1000 FIRST DRIVE NW AUSTIN MN 55912 411404075 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--AUSTIN FOUNDATION 1000 FIRST DRIVE NW AUSTIN MN 55912 300107471 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--ALBERT LEA AND AUSTIN 1 MCHS--CANNON FALLS 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 204156428 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--CHIPPEWA VALLEY INC 1501 THOMPSON STREET BLOOMER WI 54724 390980343 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--EAU CLAIRE CLINIC INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391735831 PATIENT CARE - CLINIC WI 501(C)(3) 3 MAYO CLINIC 1 MCHS--EAU CLAIRE FOUNDATION INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391633407 GRANTMAKING FOUNDATION WI 501(C)(3) 11-I MCHS--EAU CLAIRE CLINIC INC 1 MCHS--EAU CLAIRE HOSPITAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 390813418 HOSPITAL WI 501(C)(3) 3 MAYO CLINIC 1 MCHS--FAIRMONT 800 MEDICAL CENTER DRIVE PO BOX 800 FAIRMONT MN 56031 410760836 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--FRANCISCAN HEALTHCARE FOUNDATION INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391186647 FUNDRAISING FOUNDATION WI 501(C)(3) 7 MCHS--FRANCISCAN HEALTHCARE INC 1 MCHS--FRANCISCAN HEALTHCARE INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391411999 HEALTHCARE SYSTEM PARENT WI 501(C)(3) 11-I MAYO CLINIC 1 MCHS--FRANCISCAN MEDICAL CENTER INC 700 WEST AVE SOUTH LA CROSSE WI 54601 390806374 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--FRANCISCAN HEALTHCARE INC 1 MCHS--LAKE CITY 500 WEST GRANT STREET LAKE CITY MN 55041 411906820 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--MANKATO 1025 MARSH STREET MANKATO MN 56002 411236756 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--MANKATO HEALTH CARE FOUNDATION 1025 MARSH STREET MANKATO MN 56002 411663357 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--MANKATO 1 MCHS--NEW PRAGUE 301 SECOND STREET NE NEW PRAGUE MN 56071 410723639 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--NORTHLAND INC 1222 EAST WOODLAND AVENUE BARRON WI 54812 390920634 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--OAKRIDGE INC 13025 EIGHTH STREET PO BOX 70 OSSEO WI 54758 391029430 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--OWATONNA 134 SOUTHVIEW ST OWATONNA MN 55060 411862132 PATIENT CARE - CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--RED CEDAR INC 2321 STOUT ROAD MENOMONIE WI 54751 510190875 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--RED WING 701 HEWITT BOULEVARD RED WING MN 55066 411713783 PATIENT CARE SERVICES MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--SPRINGFIELD 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--ST JAMES 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 410797368 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--WASECA 501 NORTH STATE STREET WASECA MN 56093 363606405 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MILES AND SHIRLEY FITERMAN ENDOWMENT FUND FOR DIGESTIVE DISEASES 200 FIRST STREET SW ROCHESTER MN 55905 412020392 SUPPORT RESEARCH, PRACTICE & EDUCATION MN 501(C)(3) 11-I MAYO CLINIC 1 POVERELLO FOUNDATION 200 FIRST STREET SW ROCHESTER MN 55905 411494881 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MAYO CLINIC HOSPITAL - ROCHESTER 1 SATILLA HEALTH FOUNDATION INC 1900 TEBEAU STREET WAYCROSS GA 31501 582008998 FUNDRAISING FOUNDATION GA 501(C)(3) 11-III-FI N/A 0 SATILLA REGIONAL MEDICAL CENTER AUXILIARY 410 DARLING AVENUE WAYCROSS GA 31501 586066381 PROMOTE AND COMPLEMENT HEALTH CARE GA 501(C)(3) 11-I N/A 0 FRANKLIN HEATING STATION 119 THIRD ST SW ROCHESTER MN 55902 410264830 UTILITY MN N/A LATIGO PETROLEUM LLC PO BOX 14230 ODESSA TX 79768 364767494 OIL & GAS EXPLORATION DE N/A WATERSHED CAP INSTL PRTNRS III LP ONE MARITIME PLAZA SUITE 1525 SAN FRANCISCO CA 94111 462982848 INVESTMENT ACTIVITIES DE N/A AMBIENT CLINICAL ANALYTICS INC 221 1ST AVE SW SUITE 202 ROCHESTER MN 55902 800928405 SOFTWARE DE N/A C 1 BWL HOLDINGS INC 1209 ORANGE STREET WILMINGTON DE 19801 472413749 OIL & GAS EXPLORATION DE N/A C 1 CAVALRY CLO III LTD PO BOX 1093 GT QUEENSGATE HOUSE S GRAND CAYMAN CJ INVESTMENT ACTIVITIES CJ N/A C 1 CAVALRY CLO IV LTD PO BOX 1093 GT QUEENSGATE HOUSE S GRAND CAYMAN CJ INVESTMENT ACTIVITIES CJ N/A C 1 GMO GLOBAL BOND INVESTMENT FUND 78 SIR JOHN ROGERSONS QUAY DUBLIN 2 EI OTHER FINANCIAL INVESTMENT ACTIVITIES EI N/A 1 HEALTH TRADITION HEALTH PLAN 1808 EAST MAIN STREET ONALASKA WI 54650 391545987 MEDICAL SERVICES COMPANY WI N/A C 1 LOBSS NETWORK SUPPORT 2002 INC 200 FIRST STREET SW ROCHESTER MN 55905 481276150 ADMINISTRATIVE SERVICES MN N/A C 1 MAYO CLINIC GBS MAURITIUS 2ND FLOOR EBENE MEWS 57 EBENE CYBERCITY MP HEALTHCARE MANAGEMENT MP N/A C 1 MAYO CLINIC SUPPORT SERVICES TEXAS 200 FIRST STREET SW ROCHESTER MN 55905 471751102 HEALTH SERVICES TX N/A C 1 MAYO HOLDING COMPANY 200 FIRST STREET SW ROCHESTER MN 55905 411578020 HOLDING COMPANY MN N/A C 1 MAYO INSURANCE COMPANY LTD 200 FIRST STREET SW ROCHESTER MN 55905 SELF INSURANCE POOL CJ N/A C 1 MCHS--DECORAH CLINIC PHYSICIANS 907 MONTGOMERY STREET DECORAH IA 52101 411711329 PATIENT CARE - CLINIC IA N/A C 1 MCHS--PHARMACY & HOME MEDICAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 391528920 PHARMACY SERVICES WI N/A C 1 MMSI INC 200 FIRST STREET SW ROCHESTER MN 55905 411547003 THIRD PARTY ADMINISTRATION SERVICES MN N/A C 1 RESOUNDANT INC 221 1ST AVE SW SUITE 202 ROCHESTER MN 55902 461661978 MANUFACTURING MEDICAL DEVICE COMPONENT MN N/A C 1 ROCHESTER AIRPORT COMPANY 200 FIRST STREET SW ROCHESTER MN 55905 410506870 AIRPORT MANAGEMENT MN N/A C 1 SUPERBLOCK 3 PROPERTY OWNERS ASSOCIATION 13400 E SHEA BLVD SCOTTSDALE AZ 85259 860870505 COMMERCIAL PROPERTY OWNERS ASSOCIATION AZ N/A C 1 THE STABILE BUILDING OWNERS' ASSOCIATION 200 FIRST STREET SW ROCHESTER MN 55905 208994499 COMMERCIAL PROPERTY OWNERS ASSOCIATION MN N/A C 1 CHARITABLE LEAD TRUST CHARITABLE TRUST CA N/A T 1 PERPETUAL TRUST CHARITABLE TRUST ND N/A T 1 PERPETUAL TRUST CHARITABLE TRUST AZ N/A T 1 PERPETUAL TRUST CHARITABLE TRUST LA N/A T 1 PERPETUAL TRUST (2) CHARITABLE TRUST MA N/A T 1 PERPETUAL TRUST CHARITABLE TRUST MO N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST AZ N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST CO N/A T 1 CHARITABLE REMAINDER TRUST (8) CHARITABLE TRUST FL N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST LA N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST MA N/A T 1 CHARITABLE REMAINDER TRUST (77) CHARITABLE TRUST MN N/A T 1 CHARITABLE REMAINDER TRUST (2) CHARITABLE TRUST NC N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST TX N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST CO N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST IL N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST MI N/A T 1 CHARITABLE REMAINDER TRUST (64) CHARITABLE TRUST MN N/A T 1 CHARITABLE REMAINDER TRUST (7) CHARITABLE TRUST MN N/A T 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH S 663885 GAAP MMSI S 6245845 GAAP