2016-11-09T10:39:49-06:00 2015-12-31 390859910 Baker Tilly Virchow Krause LLP 225 S 6th St 2300 Minneapolis MN 55402 990 2015-01-01 411777966 North Memorial Foundation NORT 7635205200 3300 Oakdale Avenue North Robbinsdale MN 554222900 Kent Spaulding VP Foundation 7635205200 2016-11-02 1 Lawrence H Mohr CPA P00447603 6128764500 2015 2017-02-10 21:41:12Z KENT SPAULDING 3300 Oakdale Avenue North Robbinsdale MN 554222900 4059284 0 X www.northmemorial.com X 1993 MN TO SUPPORT NORTH MEMORIAL HEALTH CARE AND ITS COMMITMENT TO CHANGING AND SAVING LIVES. THROUGH PHILANTHROPY, OUR DONORS ASSIST IN GIVING OUR PATIENTS AND THEIR FAMILIES COMPASSIONATE, REMARKABLE CARE. 14 13 0 150 0 0 1649575 1464107 0 0 125014 780167 70235 398500 1844824 2642774 862277 760136 0 0 0 0 0 21007 413243 602907 840886 1465184 1622029 379640 1020745 8387281 6840610 193946 278217 8193335 6562393 X TO SUPPORT NORTH MEMORIAL HEALTH CARE AND ITS COMMITMENT TO CHANGING AND SAVING LIVES. THROUGH PHILANTHROPY, OUR DONORS ASSIST IN GIVING OUR PATIENTS AND THEIR FAMILIES COMPASSIONATE, REMARKABLE CARE. 0 1 188817 73193 HOSPICE:In 2015, North Memorial Hospice served 1,000 patients. For patients experiencing financial hardships, Foundation dollars paid for utilities, medical costs, equipment, and other expenses. The Foundation also paid for costs associated with hospice patients receiving Massage and Music Therapy services. 112293 74350 Pay It Forward Fund: This fund was established by a breast cancer survivor and her husband in October of 2005. In February of 2006, the first Pay It Forward fundraising event was held and over the last nine years more than $1.2M has been paid toward patient bills of cancer patients and their families. During 2015, the fund provided patient assistance in the amount of $151,991 with a maximum per patient of $1,500. Patients eligible for assistance are from North Memorial, Maple Grove, Mercy, Unity, Monticello, Ridgeview, and Hennepin County Medical Center. The Fund is administered at no fee through the foundation. Each year the fund helps nearly 200 patients buy groceries, pay their mortgages, heat their homes, pay for utilities, repair their cars, and assist with unfunded medical bills. The fund helps patients to pay expenses so they can focus on what's really important-getting healthy.THE PAY IT FORWARD FUND WAS TRANSFERRED TO ANOTHER, UNRELATED HOSPITAL FOUNDATION IN JUNE OF 2015. 111559 86611 SafeJourney Program: In response to community need an emergency awareness of the crucial role health care providers can play in assisting abuse victims, North Memorial Medical Center developed a comprehensive response to proactively identify and respond to patients at North Memorial and Maple Grove Hospital who are suffering from family violence. Founded in 1994, SafeJourney provides a variety of direct services, advocacy, assessment, intervention, prevention and education to assist over fourteen hundred individual victims of abuse as well as the larger community each year. Services focused on the northern and western Twin Cities suburbs and Minneapolis' north side, include 24 hours/day, seven days/week coverage of the hospital, using skilled volunteers to provide patient assessment and advocacy; two weekly support groups for battered women; and community and professional education. In 2015, over $100,000 in foundation funds was used to support over 100 volunteers serving more than 1500 domestic abuse encounters. 560621 525983 560621 525983 973290 1 1 0 0 0 1 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 31 1 0 0 0 0 0 0 1 1 0 0 0 0 X 14 13 0 0 0 0 1 1 1 1 1 0 0 1 0 1 1 0 0 0 MN WI X Aaron Bloomquist 7635814562 3300 Oakdale Avenue North Robbinsdale MN 554222900 KAREN BIRD Board Member 2.00 0.00 X 0 0 0 JIM BYRNE Secretary 2.00 0.00 X 0 0 0 SCOTT HEMENWAY Board Member 1.00 0.00 X 0 0 0 MIKE HOLTZ Board Member 2.00 0.00 X 0 0 0 DEEPAK KADEMANI DMD MD Board Member 1.00 0.00 X 0 0 0 CHENG LOR Board Member 1.00 0.00 X 0 0 0 TANYA KORPI MACLEOD Board Member 1.00 0.00 X 0 0 0 MARK NIBLICK Board Member 1.00 0.00 X 0 0 0 KRISTIN NIMSGER Board Member 1.00 0.00 X 0 0 0 DON PARK TREASURER 1.00 0.00 X X 0 0 0 BRUCE QUAM Board Member 1.00 0.00 X 0 0 0 LYNN STARKOVICH BOARD CHAIR 1.00 0.00 X X 0 0 0 MIKE STEINHAUSER SECRETARY 1.00 0.00 X X 0 0 0 J KEVIN CROSTON MD Board Member 1.00 50.00 X 0 937930 47707 LOREN TAYLOR BOARD MEMBER (PART YEAR) 1.00 50.00 X 0 488513 25829 Kent Spaulding Vice President 50.00 0.00 X 0 238386 31580 0 1664829 105116 0 0 1 0 0 215128 824827 424152 134996 1464107 122845 122845 1839224 1181902 657322 657322 657322 633108 215128 234608 398500 398500 2642774 0 0 1178667 585521 585521 174615 174615 21007 21007 3666 1505 2161 1800 1800 3642 3642 STAFF SUPPORT 803820 206207 206207 391406 uncollectible pledge 27128 27128 MISCELLANEOUS 830 830 1622029 973290 235496 413243 312487 326876 172978 73428 21267 10381 225000 225000 225000 6625176 5251729 1030373 953196 8387281 6840610 152097 243169 41849 35048 193946 278217 X 2083948 2074294 2704051 2383701 3405336 2104398 8193335 6562393 8387281 6840610 X 1020745 -797730 -10 -1853947 X X 0 1 X 1 0 X 1941680 1727243 1931145 1649575 1464107 8713750 1941680 1727243 1931145 1649575 1464107 8713750 8713750 117846 87596 102244 125014 122845 555545 9269295 0.94010 0.94860 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4 15046 20093 35048 1 1 3591423 17322 1405602 2203143 3446092 76703 118858 50230 3591423 2683970 710628 85294 33800 3446092 2382667 270795 92571 62063 2683970 2251229 72500 71751 12813 2382667 0.00000 0.95520 0.04480 1 0 225000 225000 225000 BENEFICIAL INTEREST IN REMAINDER TRUST 953196 953196 AMOUNTS HELD FOR OTHERS 35048 35048 X Part V, Line 4: 1) RALPH ROSSEN ENDOWMENT: THIS ENDOWMENT WAS ESTABLISHED IN 1986 TO PROVIDE RECOGNITION TO NURSING STAFF THAT PROVIDE REMARKABLE SERVICE TO NORTH MEMORIAL PATIENTS AND THEIR FAMILIES. MEMBERS OF THE ROSSEN FAMILY SERVE ON A COMMITTEE ALONG WITH THE VP AND CHIEF NURSING OFFICER OF NORTH MEMORIAL TO SELECT THE RECIPIENTS. 2) HAROLD B. KAISER HONORARY LECTURESHIP ENDOWMENT: DR KAISER IS THE FOUNDER OF ALLERGY & ASTHMA SPECIALISTS, P.A. ESTABLISHED IN 1966. THE HAROLD B KAISER HONORARY LECTURESHIP ENDOWMENT PROVIDES FUNDING FOR A KEYNOTE SPEAKER FOR THE ANNUAL ALLERGY & ASTHMA CONFERENCE HELD IN THE MINNEAPOLIS AREA IN MARCH. 3) HAROLD ECKER ENDOWMENT: ESTABLISHED IN 1994 IN HONOR OF THE EXCELLENT CARE THAT MR. ECKER RECEIVED AS A PATIENT AT NORTH MEMORIAL, THE HAROLD ECKER ENDOWMENT PROVIDES A $500 AWARD TO THREE NORTH MEMORIAL EMPLOYEES RECOGNIZING THEIR OUTSTANDING PERFORMANCE AND PERSONAL ATTITUDE. THE AWARD IS OPENED TO ALL EMPLOYEES AND THE WINNERS ARE SELECTED BY A COMMITTEE OF NORTH MEMORIAL EMPLOYEES AND PRESENTED AT THE ANNUAL QUALITY AWARDS LUNCHEON IN NOVEMBER EACH YEAR. 4) RESIDENTIAL HOSPICE ENDOWMENT: THE RESIDENTIAL HOSPICE ENDOWMENT WAS ESTABLISHED BY DR. JOHN AND PATTY MANION TO PROVIDE ASSISTANCE TO THE RESIDENTIAL HOSPICE PROGRAM AT NORTH MEMORIAL. FUNDS ARE USED TO UPGRADE THE FACILITIES AND EQUIPMENT AT THE NORTH RESIDENTIAL HOSPICE FACILITY IN BROOKLYN CENTER, PROVIDE ADDITIONAL PROGRAM SUPPORT, STAFF TRAINING AND TO ASSIST THOSE FAMILIES THAT CANNOT AFFORD THIS SERVICE. 5) HELEN MURRAY MEMORIAL ENDOWMENT THIS ENDOWMENT WAS ESTABLISHED WITH AN IRREVOCABLE CHARITABLE REMAINDER TRUST BY JEANNE MITHUN TO RECOGNIZE THE OUTSTANDING SERVICE THAT NORTH RESIDENTIAL HOSPICE PROVIDED TO HER MOTHER (HELEN MURRAY) AND HER FAMILY. FUNDS ARE USED TO PROVDE CARE TO INDIVIDUALS UNABLE TO PAY FOR SERVICES AT THE FACILITY. 6) PAY IT FORWARD THE PAY IT FORWARD FUND WAS ESTABLISHED BY BREAST CANCER SURVIVOR MICHELLE MOREY AND HER HUSBAND SCOTT BISSEN. MICHELLE RECOGNIZED A NEED TO HELP WOMEN STRUGGLING FINANCIALLY WHILE GOING THROUGH CANCER TREATMENT. PATIENTS ELIGIBLE FOR ASSISTANCE ARE FROM NORTH MEMORIAL, UNITY AND MONTICELLO HOSPITALS. THE FUND was ADMINISTERED AT NO FEE THROUGH THE NORTH MEMORIAL FOUNDATION. DURING 2015, NORTH MEMORIAL CEASED ADMINISTRATING THE FUND AND THE ASSETS ASSOCIATED WITH PAY IT FORWARD AND THE ASSETS ARE NO LONGER INCLUDED IN THE ENDOWMENT FUND BALANCE. 7) MEDICAL STAFF ENDOWMENT THIS ENDOWMENT WAS ESTABLISHED IN 2010 BY THE NORTH MEMORIAL MEDICAL STAFF EXECUTIVE COMMITTEE. PROCEEDS FROM THE ENDOWMENT WILL FUND NORTH MEMORIAL PROGRAMS SUCH AS JUNIOR VOLUNTEER SCHOLARSHIP, SAFEJOURNEY, PASTORAL CARE, ETC. 8) MAPLE GROVE MEDICAL STAFF ENDOWMENT WAS ESTABLISHED IN 2013 BY THE MAPLE GROVE MEDICAL STAFF EXECUTIVE COMMITTEE. PROCEEDS FROM THE ENDOWMENT WILL FUND MAPLE GROVE PROGRAMS. Part X, Line 2: North Memorial evaluates its uncertain positions on an annual basis, and there have been no uncertain tax positions recorded in 2015 or 2014. X X X X X X 1 RUFFALO NOEL LEVITZ 1025 Kirkwood Parkway SW Cedar Rapids IA 52404 CALLING PROGRAM 0 0 21007 -21007 21007 -21007 MN WI Dinner/Dance Gala 363381 113886 249495 35587 22843 53030 Pay It Forward Casino Night 263658 32835 230823 18720 5300 13923 2 221197 68407 152790 50613 34592 848236 215128 633108 104920 28143 101545 234608 398500 1 North Memorial Health Care 3300 Oakdale Ave N Robbinsdale MN 55422 410729979 501(c)(3) 336524 10203 fmv FURNITURE & FIXTURES TO SUPPORT NMHC PROGRAMS AND SERVICES North Memorial Health Care 3300 Oakdale Ave N Robbinsdale MN 55422 410729979 501(c)(3) 31129 fmv EDUCATION & CONFERENCES GRANTS IN CONNECTION WITH MEDICAL TRAINING PAID ON BEHALF OF NORTH MEMORIAL. North Memorial Health Care 3300 Oakdale Ave N Robbinsdale MN 55422 410729979 501(c)(3) 207665 fmv SUPPORT OF NORTH MEMORIAL CLINIC OPERATIONS GRANTS IN CONNECTION WITH CLINIC OPERATIONS PAID ON BEHALF OF NORTH MEMORIAL. 1 PAY IT FORWARD FUND 200 151991 EMPLOYEE ASSISTANCE 17 9999 JUNIOR VOLUNTEER SCHOLARSHIPS 9 12100 HOPE CHEST BREAST CENTER 5 525 Part I, Line 2: The organization primarily makes grants to related organization North Memorial Health Care and records are maintained as to how funds are disbursed by both organizations. The organization also paid $151,991 through the Pay It Forward Fund. Once eligibility has been determined, the organization will pay the patient's bills, such as mortgage, utilities, repairs, or unfunded medical bills. Each patient has a maximum of $1,500 and the bills are paid directly to the vendors. The organization also funds continuing education for North Memorial employees and makes several small sponsorships. 0 0 0 0 0 0 1 0 0 J KEVIN CROSTON MD Board Member 0 597577 0 335538 0 4815 0 18550 0 29157 0 985637 0 0 LOREN TAYLOR BOARD MEMBER (PART YEAR) 0 208239 0 272516 0 7758 0 18550 0 7279 0 514342 0 0 Kent Spaulding Vice President 0 184627 0 53115 0 644 0 11111 0 20469 0 269966 0 0 Part I, Line 3 The Chief Executive Officer of North Memorial provides services to North Memorial Health Care as well as to all related entities as identified on Schedule R. As such, his compensation level incorporates services provided to multiple North Memorial entities. Both Loren Taylor and Dr. Kevin Croston served as CEO of North Memorial Health Care for part of the year. The CEO of North Memorial Health Care has a permanent spot on the board of the North Memorial Foundation. Part I, Line 6 North Memorial Health Care's annual incentive plan requires achievement of stated performance metrics, which include operating cash flow margin. X SILENT AUCTION BASKETS 625 125497 FMV X technical support 2 6456 fmv X golf balls 195 2925 FMV X SUPPLIES 1 118 FMV 0 0 0 0 Part I, Column (b): CONTAINS THE NUMBER OF CONTRIBUTORS. Form 990, Part III, line 3 THE PAY IT FORWARD FUND WAS TRANSFERRED TO ANOTHER, UNRELATED HOSPITAL FOUNDATION IN JUNE OF 2015. Form 990, Part VI, Section A, line 6 NORTH MEMORIAL HEALTH CARE IS THE SOLE MEMBER OF THE ORGANIZATION. Form 990, Part VI, Section A, line 7a NORTH MEMORIAL HEALTH CARE, AS THE SOLE MEMBER OF THE ORGANIZATION, DETERMINES THE NUMBER OF BOARD MEMBERS AND ELECTS MEMBERS AT THE ANNUAL MEETING AFTER CONSIDERATION OF NOMINATIONS, IF ANY, FROM THE BOARD OF DIRECTORS. Form 990, Part VI, Section A, line 7b THE APPROVAL OF NORTH MEMORIAL HEALTH CARE AS THE SOLE MEMBER OF THE ORGANIZATION IS REQUIRED FOR THE FOLLOWING ACTIONS OF THE ORGANIZATION'S GOVERNING BODY: (1) AMENDMENTS TO THE GOVERNING DOCUMENTS; (2) MERGER OR CONSOLIDATION OF THE ORGANIZATION; (3) SALE, LEASE, PLEDGE, TRANSFER, ASSIGNMENT OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION; (4) MORTGAGES OR OTHER SECURITY INTERESTS AFFECTING ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION; (5) ISSUANCE OF CAPITAL CALLS TO THE MEMBER; AND (6) DISSOLUTION AND LIQUIDATION OF THE ORGANIZATION. Form 990, Part VI, Section B, line 11 The Form 990 will be distributed to all board members at the meeting closest to the filing date for review and approval. Form 990, Part VI, Section B, line 12 NORTH MEMORIAL FOUNDATION DOES NOT HAVE A CONFLICT OF INTEREST POLICY THAT COVERS CERTAIN EMPLOYEES, PHYSICIANS AND BOARD MEMBERS. THE BOARD OF DIRECTORS WILL SIGN A CONFLICT OF INTEREST POLICY IN 2016 AND GOING FORWARD. Form 990, Part VI, Section B, line 15 The organization's officers received their compensation from North Memorial Health Care (NMHC) which follows NMHC's policies and procedures on determining compensation. Form 990, Part VI, Section C, line 19 The Foundation makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part XI, line 9: TRANSFER OF PIFF ENDOWMENT TO ANOTHER HOSPITAL FOUNDATION -1,853,947. Form 990, Part XII, Line 2c: NEITHER THE OVERSIGHT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT CHANGED DURING THE TAX YEAR. North Memorial Health Care 3300 Oakdale Ave N Robbinsdale MN 55422 410729979 ACUTE CARE MN 501(c)(3) Line 3 North Memorial 0 Associated Health Assurance 3300 Oakdale Ave N Robbinsdale MN 55422 980343815 insurance BD 501(c)(3) 11A North Memorial 0 Maple Grove Hospital Corporation 3300 Oakdale Ave N Robbinsdale MN 55422 208316475 ACUTE CARE MN 501(c)(3) Line 3 North Memorial 0 NORTH MEMORIAL AMBULATORY SURGERY CENTER AT MAPLE GROVE LLC 9855 HOSPITAL DRIVE MAPLE GROVE MN 55369 260393039 OUTPATIENT SURGERY MN N/A MINNESOTA DIAGNOSTIC IMAGING PARTNERS LLC 2955 XENIUM LANE SUITE 40 PLYMOUTH MN 55441 352162215 RADIOLOGY MN N/A NORTH RADIATION THERAPY CENTER LLC 6950 FRANCE AVE S SUITE 200 EDINA MN 55435 743069974 RADIOLOGY MN N/A BLAINE URGENCY CENTER LLC 480 OSBORNE RD FRIDLEY MN 55432 461630126 URGENT CARE MN N/A PLYMOUTH CITY CENTER MEDICAL BUIDING 5700 SMETANA DRIVE SUITE 120 MINNETONKA MN 55343 463883617 Medical Office Building MN N/A MINNETONKA AMBULATORY SURGERY CENTER 3300 oakdale Avenue North Robbinsdale MN 55422 465653486 OutpatIENT SURGERY MN N/A CRYSTAL IMAGING CENTER LLC 2955 XENIUM LANE SUITE 40 PLYMOUTH MN 55441 454265124 RADIOLOGY MN N/A OAKDALE HEALTH ENTERPRISES INC 3300 Oakdale Ave N ROBBINSDALE MN 55422 411546422 AMBULANCE MN N/A C 0 CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST MN N/A T 0 NORTH COLLABORATIVE CARE 3300 Oakdale Ave N ROBBINSDALE MN 55422 461680666 primary care MN N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 North Memorial Health Care (contributions to NMHC) B 346727 FMV NORTH MEMORIAL HEALTH CARE (STAFF SUPPORT) O 824827 FMV