2016-11-10T15:05:55-06:00 2015-12-31 990 2015-01-01 204156428 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS MAYO 5075381297 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 JAMES J TARASOVITCH REGION CFO 5072634221 2016-11-10 2015 2017-02-10 21:41:12Z DAVID C AGERTER MD 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 36664281 0 5983 X WWW.MAYOCLINICHEALTHSYSTEM.ORG X 2006 MN OPERATION OF A HOSPITAL AND CLINIC 9 4 431 49 0 0 395892 5248430 27284171 30773509 439950 355042 53160 96988 28173173 36473969 7917 750 0 0 13040096 14262538 15000 7500 7500 12428761 14285974 25491774 28556762 2681399 7917207 47754061 38679700 24096108 7398447 23657953 31281253 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 24042817 30841213 PATIENT SERVICES (HOSPITAL & CLINIC) - SEE SCHEDULE OPATIENT CARE: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.IN 2015, MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) HAD 247 MEDICAL/SURGICAL ADMISSIONS AND 127 SWING BED ADMISSIONS WITH AN AVERAGE DAILY CENSUS OF 8.5. THERE WERE ALSO 3,948 EMERGENCY ROOM VISITS AND 215 OUTPATIENT SURGERIES. MCHS-CF PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER THEIR CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. IN 2015, THE COST OF CHARITY CARE PROVIDED BY MCHS-CF WAS APPROXIMATELY $162,500.SERVICES ARE ALSO PROVIDED TO MEDICAID AND MEDICARE PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. IN ADDITION, SERVICES ARE PROVIDED TO PATIENTS UNDER OTHER MEANS-TESTED GOVERNMENT PROGRAMS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. THE COST OF UNCOMPENSATED CARE PROVIDED TO LOW INCOME PATIENTS THROUGH MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS WAS APPROXIMATELY $1,415,000. THIS AMOUNT INCLUDES A MEDICAID SURCHARGE OF $449,936.MCHS-CF PROVIDES SUPPORT SERVICES TO AFFILIATED ORGANIZATIONS TO HELP FURTHER THEIR EXEMPT PURPOSE OF PROVIDING PATIENT CARE. 161778 750 24284 COMMUNITY OUTREACH - SEE SCHEDULE OMAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) PARTICIPATES IN COMMUNITY AND WELLNESS EVENTS WHERE FREE OR NOMINAL FEE SCREENING TESTS ARE OFFERED AS WELL AS FREE PATIENT EDUCATION MATERIALS. THESE EVENTS INCLUDE FIRST THURSDAYS, SHEPHERDS CENTER, AND TWIN RIVERS. FLU SHOTS WERE GIVEN TO VOLUNTEER FIREFIGHTERS AND AMBULANCE RESPONDERS. EMERGENCY PREPAREDNESS TRAINING WAS PROVIDED TO 50 MEMBERS OF THE ARMY RESERVE DURING TWO TRAINING SESSIONS AT THE MEDICAL CENTER. FREE COMMUNITY SCREENING FOR DIABETES IS DONE THROUGH A PARTNERSHIP WITH THE LOCAL LIONS CLUB AT THE MEDICAL CENTER ON AN ANNUAL BASIS. MCHS-CF MEALS ON WHEELS PROGRAM PROVIDES FREE HOME DELIVERED NOON MEALS TO HOMEBOUND SENIORS OVER 60 WITH A MODERATE TO HIGH NUTRITIONAL RISK. THIS YEAR THE PROGRAM EXPANDED TO A SENIOR HOUSING SITE AND DOUBLED THE PARTICIPATION. THIS PROGRAM IS AVAILABLE ON AN ANNUAL BASIS, MONDAY THROUGH FRIDAY TO APPROXIMATELY 30 TO 35 DAILY PARTICIPANTS WITH MORE THAN 225 DIFFERENT COMMUNITY MEMBERS RECEIVING MEALS DURING 2015. MCHS-CANNON FALLS STAFF PARTICIPATED IN THE BOOK READ "GOOD FOR YOU AND ME" PROMOTING THE 5-2-1-0 NUTRITION AND ACTIVITY PROGRAM WITH PRIMARY CARE AND PEDIATRIC STAFF. MCHS-CANNON FALLS OFFERED SPORTS PHYSICALS AT A REDUCED RATE FOR 15 STUDENTS WHO ARE PARTICIPATING IN SPORTS THROUGH THE LOCAL SCHOOLS. MCHS-CF AUXILIARY PROVIDES APPROXIMATELY 45 VOLUNTEERS TO GREET AND DIRECT PATIENTS DURING HIGH-VOLUME SURGERY WEEKDAYS AND OFFERS CLERICAL SUPPORT TO STAFF. THE AUXILIARY VOLUNTEERS PROVIDED APPROXIMATELY 914 HOURS OF VOLUNTEER SERVICES. BASED ON THE 2015 INDEPENDENT SECTOR STATISTICS, THE APPROXIMATE VALUE OF THESE SERVICES IS $21,530.MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CANNON FALLS) DETERMINES PATIENT NEEDS THROUGH A VARIETY OF MEANS: DIRECT FEEDBACK FROM PATIENTS TO EMPLOYEES AT POINT OF CARE AND AT OTHER OPPORTUNITIES, THROUGH COMMUNITY REPRESENTATION ON THE MEDICAL CENTER COMMUNITY ADVISORY COUNCIL AND THROUGH CONTINUAL, RANDOM, CONFIDENTIAL PATIENT SATISFACTION SURVEYS WHICH ARE PART OF THE DECISION-MAKING PROCESSES FOR IMPROVING PATIENT CARE AND CUSTOMER SERVICE. MCHS-CANNON FALLS EMPLOYEES ARE ALSO STRONGLY CONNECTED WITH LOCAL CIVIC GROUPS. MANY EMPLOYEES ARE ACTIVE MEMBERS OF VARIOUS CANNON FALLS ORGANIZATIONS, WHILE OTHERS GIVE HEALTHCARE PRESENTATIONS TO THESE GROUPS. THIS PARTICIPATION NOT ONLY PROMOTES INVOLVEMENT IN THE COMMUNITY, BUT ALSO GIVES COMMUNITY MEMBERS A CHANCE TO ASK QUESTIONS, SHARE COMMENTS, CONCERNS OR OTHER SUGGESTIONS THEY MAY HAVE REGARDING THE MEDICAL CENTER. MCHS-CANNON FALLS EMPLOYEES PROMOTE THE ACTIVE REFERRAL OF PATIENTS TO LOCAL RESOURCES SUCH AS ACCESS TO HIGH QUALITY NUTRITIOUS FOODS, PHYSICAL ACTIVITY AND TOBACCO USE CESSATION PROGRAMS. 24204595 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 0 0 431 1 0 0 0 0 0 0 0 0 0 0 X 9 4 1 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 MN X MAYO CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 AGERTER MD DAVID C DIRECTOR/REGION CEO 1.00 40.00 X X 0 597592 26206 ALTRICHTER MD PAUL M DIRECTOR/VICE CHAIR 1.00 40.00 X X 0 261530 55754 BAILEY TED DIRECTOR 1.00 0.00 X 0 0 0 BERNARD MD MATTHEW E DIRECTOR 1.00 40.00 X 0 267909 58710 MOUW JEROMY J DIRECTOR 1.00 0.00 X 0 0 0 PARKS DOUGLAS A DIRECTOR/REGION CAO 1.00 40.00 X X 0 239099 50017 SJOQUIST MARK E DIRECTOR 1.00 0.00 X 0 0 0 WHITED MD BRIAN L DIRECTOR 1.00 40.00 X 0 476401 69631 WITT MD THOMAS J DIRECTOR/CHAIR/CEO 1.00 40.00 X X 0 474073 69829 WULF GREG DIRECTOR 1.00 0.00 X 0 0 0 GUDGELL STEPHEN F TREASURER 1.00 40.00 X 0 203028 24335 KOCH MARK B ASSISTANT SECRETARY 1.00 40.00 X 0 483196 23677 PRIEST WILLIAM F SECRETARY 40.00 0.00 X 194479 0 51686 TARASOVITCH JAMES J REGION CFO 1.00 40.00 X 0 309144 66950 CHESTNUT MD JANET S PHYSICIAN 40.00 0.00 X 341202 0 69618 JOHNSTON-FLANDERS MD MEGAN S PHYSICIAN 40.00 0.00 X 244406 0 50127 NORDAHL MD THOMAS W PHYSICIAN 40.00 0.00 X 577198 0 67355 STRICKER MD ALEXANDER W PHYSICIAN 40.00 0.00 X 274902 0 35174 TURNA MD TARLOCHAN S PHYSICIAN 40.00 0.00 X 565068 0 45105 CHRISTIAN GLENN P FORMER OFFICER 40.00 0.00 X 187481 0 42269 LOHR MD ROBERT H FORMER OFFICER 0.00 40.00 X 0 171518 0 2384736 3483490 806443 18 1 1 0 MAYO CLINIC HEALTH SYSTEM-ALBERT LEA AND 1000 FIRST DRIVE NW AUSTIN MN 55912 PURCHASED SERVICES 2475310 MAYO FND FOR MEDICAL EDUCATION AND RESEA 200 FIRST STREET SW ROCHESTER MN 55905 PURCHASING AGENT 778945 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 LAB & OTHER SUPPORT SERVICES 191212 TW WALTER ANESTHESIA SERVICES INC 17189 COUNTY 27 BLVD PINE ISLAND MN 55963 ANESTHESIA (CRNA) 158621 4 5180870 67560 5248430 NET PATIENT REVENUE 620000 29755098 29755098 SHARED SERVICES 561000 1018411 1018411 30773509 315136 315136 230218 190312 39906 39906 39906 CAFETERIA/VENDING 722210 89873 89873 MEDICAL DIRECTOR FEES 541900 5000 5000 MISC. REVENUE 900099 2115 2115 96988 36473969 30865497 0 360042 X 750 750 246165 246165 1587605 1254726 332879 9420521 9066241 354280 1001260 963605 37655 1333361 1283217 50144 673626 648293 25333 240 240 164 164 7500 7500 6757248 4191507 2565741 150 150 789214 424841 364373 3474 3434 40 402071 350044 52027 126453 97396 29057 4429 2068 2361 2528755 2289304 239451 36503 36503 MEDICAL SUPPLIES 1736491 1736491 BAD DEBT EXPENSE 1392234 1392234 MN CARE TAX 270328 270328 MEDICAID SURCHARGE 179609 179609 58611 50193 8418 28556762 24204595 4344667 7500 496 68428 2107557 1097052 6252510 4862637 285199 308052 64178 0 33717496 4447967 30617230 29269529 8426891 999750 0 2074252 47754061 38679700 3289541 2439579 20806567 4958868 24096108 7398447 X 21585758 28951137 2019615 2277536 52580 52580 23657953 31281253 47754061 38679700 X 7917207 -2342 -291565 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 164 164 0 PART II-B, LINE 1: THE AMOUNT IN "OTHER ACTIVITIES" REPRESENTS A PORTION OF PROFESSIONAL DUES ATTRIBUTABLE TO LOBBYING. 52580 52580 52580 52580 52580 1087 1087 52580 52580 1066 1066 52580 52580 52580 1.00000 0 1 1 661782 661782 28136395 2511284 25625111 4919319 1936683 2982636 29269529 DUE FROM AFFILIATES 2056604 DEFERRED COMPENSATION 17648 2074252 DUE TO AFFILIATES 4941220 DEFERRED COMPENSATION LIABILITY 17648 4958868 X PART V, LINE 4: THE ENDOWMENT FUNDS PROVIDE A STABLE FUNDING SOURCE TO SUPPORT THE MISSION OF THE ORGANIZATION. 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. 1 1 X 1 X 1 X 1 0 1 1 162545 162545 0.00600 2827405 1412585 1414820 0.05210 2989950 1412585 1577365 0.05810 4290 4290 0.00020 9810 9810 0.00040 144489 24284 120205 0.00440 158589 24284 134305 0.00500 3148539 1436869 1711670 0.06310 3189 3189 0.00010 3189 3189 0.00010 0 1392234 9994300 10072759 -78459 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 MAYOCLINICHEALTHSYSTEM.ORG 140 X X X X MAYO CLINIC HEALTH SYSTEM-CANNON FALLS 1 0 0 1 X X X X X X X 13 1 1 0 1 X 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 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-CANNON FALLS PART V, SECTION B, LINE 5: INPUT WAS PROVIDED BY THE HEALTHY COMMUNITIES SUPERVISOR AND COMMUNITY HEALTH SPECIALIST OF THE PUBLIC HEALTH DIVISION OF GOODHUE COUNTY HEALTH AND HUMAN SERVICES AND THE DIRECTOR OF WABASHA COUNTY PUBLIC HEALTH. IN ADDITION, INPUT WAS RECEIVED FROM KEY INFORMANT INTERVIEWS, COUNTY-WIDE MAIL SURVEYS, LOCAL FOCUS GROUPS, AND SURVEYS COMPLETED BY THE SCHOOL DISTRICTS, AND THE CHEMICAL HEALTH INITIATIVE. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS PART V, SECTION B, LINE 6A: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS, MAYO CLINIC HEALTH SYSTEM-LAKE CITY, AND MAYO CLINIC HEALTH SYSTEM-RED WING COLLABORATED ON THE CHNA WHICH ENCOMPASSES THE COUNTIES THAT THE THREE HOSPITALS SERVE. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS PART V, SECTION B, LINE 11: MAYO CLINIC HEALTH SYSTEM (MCHS) IN LAKE CITY, CANNON FALLS AND RED WING IDENTIFIED THREE SIGNIFICANT HEALTH NEEDS IN GOODHUE COUNTY IN PARTNERSHIP WITH GOODHUE COUNTY HEALTH AND HUMAN SERVICES. OBESITY - RELATED TO ACTIVITY, NUTRITION AND CHRONIC DISEASE, MENTAL HEALTH AND ACCESS TO CARE WERE CHOSEN AS THE TOP THREE HEALTH PRIORITIES. ONGOING PARTNERSHIPS WITH LOCAL PUBLIC HEALTH, SENIOR SERVICE PROGRAMS, NON PROFITS AND OTHER COMMUNITY ORGANIZATIONS ARE INTEGRAL TO IMPROVING THE HEALTH AND QUALITY OF LIFE FOR AREA RESIDENTSMCHS IN CANNON FALLS, LAKE CITY, AND RED WING COLLABORATED ON A JOINT COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS, IDENTIFIED COMMON NEEDS, AND DEVELOPED THE FOLLOWING JOINT IMPLEMENTATION PLANS TO ADDRESS THE NEEDS IDENTIFIED IN THE ASSESSMENT.IDENTIFIED NEED: OBESITYGOAL: INCREASE AWARENESS OF INDIVIDUAL HEALTH AND OBESITY MANAGEMENT OPTIONS FOR YOUTH AND FAMILIES.SOCIAL MEDIA STRATEGY - MCHS-CANNON FALLS UTILIZED SOCIAL MEDIA TO PROMOTE THE MAYO MESSAGES FOR HEALTHY ACTIVITY AND NUTRITION. PINS AND POSTS THAT FOLLOW TRENDS AND HEALTH EVENTS ARE UPDATED DAILY. THE MEDIA TEAM CONTINUES TO WORK ON HOW TO QUANTIFY THE EFFECT THESE HEALTHY AND POSITIVE MESSAGES HAVE ON THE REGION. SOCIAL MEDIA ALLOWS VARIOUS DEMOGRAPHIC AUDIENCES THAT INCLUDE MALES AND FEMALES AGES 18-64 TO RECEIVE EDUCATION AND ENGAGE ONLINE WITH MAYO CLINIC HEALTH SYSTEM. MCHS SOCIAL MEDIA CHANNELS INCLUDE: FACEBOOK, TWITTER, YOUTUBE, PINTEREST AND GOOGLE PLUS. EXAMPLES OF STRATEGIC SOCIAL MEDIA CAMPAIGNS INCLUDE RUNNING TIPS, HEALTHY RECIPES, HEART HEALTH TIPS, EXERCISE, AND WELLNESS INFORMATION. WRITTEN CONTENT, PHOTOS AND VIDEOS ARE INCORPORATED AS APPLICABLE IN EACH SOCIAL MEDIA CHANNEL. BLOGS WRITTEN BY PROVIDERS INCORPORATE KEY WELLNESS MESSAGES AND REACH IS TRACKED BY THE NUMBER OF LIKES EACH RECIEVES. 5210 STRATEGY - THE 5210 PROGRAM HAS BEEN PROMOTED IN PEDIATRICS AND FAMILY PRACTICE THROUGH 5210 FLYERS AND "HEALTHY KIDS EAT WELL TO GROW STRONG" BOOKLET AT COMMUNITY EVENTS AND IN CLINIC VISITS. THE 5210 PROGRAM WAS PROMOTED IN A COMMUNITY BOOK READ THAT TOOK PLACE IN LOCAL DAY CARE HOMES AND CENTERS. THE MAYER MERCER BOOK, "GOOD FOR YOU AND ME" WAS READ TO CHILDREN, 5210 CARDS AND RIVER CITY KIDS FUN RUN INFORMATION WAS DISTRIBUTED. CHILDREN WERE INVITED TO BRING THEIR PARENTS TO THE PARK AND WALK WITH LOCAL PEDIATRICIANS ON MONDAYS IN JUNE AND JULY. THE FUN RUN ATTENDANCE INCREASED BY 2/3 TO 150 PARTICIPANTS AFTER THIS PROMOTION. COMMUNITY EVENT SPONSORSHIP AND PROGRAMMING - MCHS-CANNON FALLS PARTNERED WITH LOCAL NONPROFITS TO ENCOURAGE HEALTHY LIVING COMMUNITY EVENTS INCLUDING BIKE RALLIES, RUN/WALKS, DANCE TEAM AND BOMBER SPIRIT EVENTS. IN ORDER TO ROLE MODEL ACTIVITY, MINI FRISBEES ARE DISTRIBUTED RATHER THAN TREATS AT YOUTH EVENTS, BIKE HELMETS ARE USED AS GIVE A WAYS, AND COOKBOOKS ARE DISTRIBUTED WITH THE MAYO CLINIC GUIDE TO SELFCARE. MCHS SPONSORS NUTRITIONAL EDUCATION AT COMMUNITY EVENTS AND MEETINGS, EMPHASIZING PLATE SIZE, NUTRITION NEEDS AND WEIGHT LOSS EDUCATION. CHILDHOOD OBESITY - LACTATION STAFF WORK WITH CHILDBIRTH EDUCATION (197 PARTICIPANTS IN BABY NUTRITION), THE BABY CAF (107 VISITS) AND THE BREAST FEEDING COALITION (COMMUNITY EDUCATION AND GOODHUE COUNTY FAIR BOOTH) TO PROVIDE ONGOING EDUCATION FOR NEW MOMS AND FAMILIES. PEDIATRIC STUDIES INDICATE BREAST FEEDING IS A FIRST STEP TO REDUCE OBESITY IN CHILDREN. LACTATION STAFF PRESENTED NUTRITION AND WEIGHT INFORMATION TO 120 PARTICIPANTS IN THE DAY CARE COALITION.IDENTIFIED NEED: ACCESSGOAL: TO SUPPORT AND PROMOTE COMMUNITY HEALTH CARE ACCESS.MCHS IN CANNON FALLS, LAKE CITY, AND RED WING PARTNERS WITH LOCAL VOLUNTEERS, COUNTY SERVICES, THE CARE CLINIC BOARD OF DIRECTORS AND CARE CLINIC STAFF TO MAINTAIN A FREE CLINIC FOR THE SERVICE AREA. MALPRACTICE INSURANCE IS PROVIDED FOR ALL MCHS EMPLOYEES WHO VOLUNTEER AT THE CLINIC. THE CARE CLINIC IS LOCATED IN THE MCHS BUILDING THAT WAS PREVIOUSLY THE RED WING HOSPITAL EMERGENCY ROOM. TECHNOLOGY IS PROVIDED TO CONNECT THE VOLUNTEER PROVIDERS WITH THE PATIENT RECORDS AND TEST RESULTS WHILE MAINTAINING THE HIGHEST LEVEL OF PATIENT CONFIDENTIALITY. SPECIALTY SERVICES (DENTAL HEALTH, DERMATOLOGY, DIABETES, OPHTHALMOLOGY, ORTHOPEDICS, PODIATRY, WOMENS HEALTH) AT THE CLINIC ARE SUPPORTED WITH TIME AND EQUIPMENT. THE CARE CLINIC SERVED 693 UNIQUE PATIENTS WITH 1,158 ENCOUNTERS IN 2015.THE NURSE TRIAGE LINE PROMOTES ACCESS TO SERVICES FOR COMMUNITY MEMBERS WHETHER THEY ARE CURRENT OR NON-CURRENT PATIENTS. THE TRIAGE STAFF ARE ABLE TO DIRECT INDIVIDUALS WHO CALL ASKING FOR ADVICE TO APPROPRIATE LEVELS OF SERVICE AND MANY TIMES ARE ABLE TO SAVE THEM FROM AN APPOINTMENT BY PROVIDING OVER THE COUNTER OPTIONS. LIMITED PROTOCOLS CAN BE SHARED WITH NON PATIENTS INCREASING THEIR ACCESS TO CARE. THE QUANTITATIVE VALUE OF THIS SERVICE IS NOT TRACKED BY ZIP CODE AND VALUES CAN NOT BE ATTRIBUTED TO SPECIFIC EINS.IDENTIFIED NEED: MENTAL HEALTHGOAL: EDUCATE AND PROVIDE RESOURCES FOR THE COMMUNITY BY UTILIZING SOCIAL MEDIA.DR. SOOD'S "GUIDE TO STRESS FREE LIVING" BOOK HAS HAD MULTIPLE FACEBOOK POSTS TO PROMOTE MENTAL HEALTH AND PERSONAL STRESS MANAGEMENT. DR. SOOD'S BOOK IS USED TO PROMOTE MENTAL HEALTH AT COMMUNITY EVENTS AND HIS BLOG IS SHARED ACROSS THE REGION. A COMMUNITY COLLABORATION LED BY MCHS IN CANNON FALLS, LAKE CITY AND RED WING ALONG WITH THE RED WING SHOE FOUNDATION SUCCEEDED IN MEETING THEIR 3 ESTABLISHED GOALS - 1) COUNTY WIDE RESOURCE LISTS WERE DEVELOPED AND SHARED, 2) NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI) CHAPTER WAS REINSTATED IN GOODHUE COUNTY, AND 3) THE "MAKE IT OK" ANTI STIGMA PROGRAM WAS PRESENTED. "MAKE IT OK" HAS BECOME A COUNTY WIDE TRAINING PROGRAM FOR MENTAL HEALTH FIRST AID WITH TRAINING HELD AT THE COUNTY SCHOOL DISTRICTS. "MAKE IT OK" ANTI STIGMA EDUCATION CONTINUES AS A PARTNERSHIP WITH GOODHUE COUNTY HEALTH AND HUMAN SERVICES. MENTAL HEALTH CLINICAL SERVICES WERE EXPANDED IN SOUTHEAST MINNESOTA BY BLENDING THE CMS COMPASS CARE COORDINATION MODEL INTO THE ADULT COMPLEX CARE COORDINATION MODEL TO IDENTIFY PEOPLE WITH MENTAL HEALTH ISSUES AT CLINIC VISITS FOR OTHER HEALTH ISSUES.THE COMPASS MODEL IS BUILT ON A REFERRAL PROCESS WHERE PATIENTS WITH CHRONIC DISEASE ARE IDENTIFIED, SCREENED AND REFERRED FOR MENTAL HEALTH CARE. AS THE PRIORITY HEALTH NEED IDENTIFIED, ADDRESSING MENTAL HEALTH IS CRUCIAL TO MAKING IMPROVEMENTS IN CHRONIC DISEASES AND OBESITY. BEGINNING IN 2015, ALL PATIENTS NEEDING CARE COORDINATION HAVE A PSYCHIATRIST ENGAGED IN THE CARE COORDINATION TEAM. TO FURTHER ASSIST WITH THE ENORMITY OF MENTAL HEALTH NEEDS IDENTIFIED IN THE 2013 CHNA AND TO INCREASE ACCESS TO CARE, NEW LICENSED SOCIAL WORKERS AND MENTAL HEALTH PROVIDERS WERE HIRED TO ACCOMMODATE PATIENT NEEDS.THE CARE CLINIC PARTNERSHIP RECEIVED A GRANT FOR A HISPANIC MENTAL HEALTH PROGRAM. THIS COUNTY WIDE BENEFIT HAS IMPACTED 230 PATIENTS IN 2015 WITH A BILINGUAL THERAPIST AND MCHS'S INCREASED SPACE GIFT FOR THIS SERVICE. THIS IS IN ADDITION TO THE PSYCHOLOGY SERVICES OFFERED AT THE FREE CLINIC. IDENTIFIED NEED: HIGHWAY SAFETYTHE CITY OF CANNON FALLS SPECIFICALLY ASSESSED THE NEED TO INCREASE SAFETY ON HIGHWAY 52. AFTER THE ASSESSMENT WAS COMPLETE, THE STATE REVEALED PLANS TO ELIMINATE ALL CROSSOVER TRAFFIC IN CANNON FALLS. THESE CHANGES WERE IMPLEMENTED AS PART OF THE HIGHWAY 52 RECONSTRUCTION DURING 2014. A COMMUNITY GROUP HAS BEEN FORMED TO LEAD DISCUSSIONS ON REOPENING ONE OF THE HIGHWAY 52 CROSSINGS. IF THIS HAPPENS, THIS SAFETY NEED WILL NEED TO BE ADDRESSED AT THAT TIME. MCHS-CANNON FALLS CONTINUES TO WORK WITH LOCAL AMBULANCE SERVICES AND THE ZERO DEATH CORRIDOR PROJECT.NEEDS NOT BEING ADDRESSED: CHEMICAL HEALTH: A TEN YEAR GOVERNMENT GRANT CONCLUDED IN OCTOBER. THIS WORK FROM THE GOODHUE COUNTY FAMILY SERVICE COLLABORATIVE HAS MOVED INTO THE MENTAL HEALTH ASSESSMENT FOR THE COUNTY SCHOOL SYSTEM. MCHS RED WING PROVIDED OFFICE SPACE AND LEADERSHIP FOR THIS GRANT DURING THEIR TEN YEARS IN GOODHUE COUNTY. TOBACCO: PROGRAMS ARE SUPPORTED IN THE COUNTY THROUGH HEALTH AND HUMAN SERVICES. MCHS DOES HAVE A CESSATION PROGRAM AND WORKS WITH OTHER STATE AND LOCAL REDUCTION EDUCATION PROGRAMS. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS 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-CANNON FALLS 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-CANNON FALLS 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-CANNON FALLS 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, BROCHURES ARE AVAILABLE 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-CANNON FALLS PART V, SECTION B, LINE 22D: OUR POLICY ALLOWS FOR A MINIMUM DISCOUNT OF 40% TO ELIGIBLE INDIVIDUALS WHICH RESULTS IN AN AMOUNT LESS THAN THE AVERAGE OF THE THREE BEST NEGOTIATED COMMERCIAL RATES OR THE BEST NEGOTIATED COMMERCIAL RATE. 1 1 - MAYO CLINIC HEALTH SYSTEM-CANNON FALLS 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 CLINIC, SWING BED, DME 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 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 $ 1,392,234. PART I, LINE 5A 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 DONATIONS AND GRANTS TO PUBLIC, PRIVATE AND NONPROFIT ORGANIZATIONS, THE FILING ORGANIZATION ASSISTS WITH SUSTAINING AND ENHANCING THE COMMUNITIES IT SERVES. 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. PART III, LINE 4: 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.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 MEDICARE SHORTFALL 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).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: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CANNON FALLS) DETERMINES PATIENT NEEDS THROUGH A VARIETY OF MEANS: DIRECT FEEDBACK FROM PATIENTS TO EMPLOYEES AT POINT OF CARE AND AT OTHER OPPORTUNITIES, THROUGH COMMUNITY REPRESENTATION ON THE MEDICAL CENTER COMMUNITY ADVISORY COUNCIL AND THROUGH CONTINUAL, RANDOM, CONFIDENTIAL PATIENT SATISFACTION SURVEYS WHICH ARE PART OF THE DECISION-MAKING PROCESSES FOR IMPROVING PATIENT CARE AND CUSTOMER SERVICE.MCHS-CANNON FALLS EMPLOYEES ARE ALSO STRONGLY CONNECTED WITH LOCAL CIVIC GROUPS. MANY EMPLOYEES ARE ACTIVE MEMBERS OF VARIOUS CANNON FALLS ORGANIZATIONS, WHILE OTHERS GIVE HEALTHCARE PRESENTATIONS TO THESE GROUPS. THIS PARTICIPATION NOT ONLY PROMOTES INVOLVEMENT IN THE COMMUNITY, BUT ALSO GIVES COMMUNITY MEMBERS A CHANCE TO ASK QUESTIONS, SHARE COMMENTS, CONCERNS OR OTHER SUGGESTIONS THEY MAY HAVE REGARDING THE MEDICAL CENTER. MCHS-CANNON FALLS EMPLOYEES PROMOTE THE ACTIVE REFERRAL OF PATIENTS TO LOCAL RESOURCES SUCH AS ACCESS TO HIGH QUALITY NUTRITIOUS FOODS, PHYSICAL ACTIVITY AND TOBACCO USE CESSATION PROGRAMS. MCHS-CANNON FALLS ACTIVELY SEEKS FEEDBACK FROM PATIENTS AND COMMUNITY MEMBERS THROUGH ITS PATIENT ADVISORY COUNCIL (PAC) AND PATIENT SATISFACTION SURVEYS. THE PAC IS A GROUP OF TEN COMMUNITY MEMBERS WHO SERVE AS A MCHS-CANNON FALLS /LAKE CITY/ RED WING FOCUS GROUP TO PROVIDE FEEDBACK PRIOR TO THE IMPLEMENTATION OF NEW PROGRAMS AND SERVICES, ASSIST IN THE IDENTIFICATION OF OPPORTUNITIES THAT WILL IMPROVE PATIENT AND FAMILY SATISFACTION, PROVIDE TIMELY AND DIRECT INPUT INTO MCHS-CANNON FALLS SYSTEM AND PROCESS CHANGES, OFFER INPUT TO LEADERSHIP IN THE PLANNING AND EVALUATION OF SERVICES, AND SERVE AS A VITAL LINK BETWEEN MCHS-CANNON FALLS AND THE COMMUNITY.MCHS-CANNON FALLS STAFF IS TRAINED TO IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE PROGRAMS. THE ORGANIZATION HAS PROGRAMS IN PLACE FOR FINANCIAL ASSISTANCE TO HELP THOSE WHO ARE IN NEED OF HEALTH CARE BUT HAVE NO INSURANCE OR ARE NOT ABLE TO RECEIVE OTHER FINANCIAL ASSISTANCE.AS THESE EXAMPLES OF INVOLVEMENT DEMONSTRATE, MCHS-CANNON FALLS IS CLOSELY CONNECTED WITH THE COMMUNITY. IN ADDITION TO THIS, MCHS-CANNON FALLS ACTIVELY SEEKS FEEDBACK FROM PATIENTS AND COMMUNITY MEMBERS THROUGH AVATAR SURVEYS. THE SURVEY IS SENT TO A CROSS SECTION OF PATIENTS TO COMPILE USEFUL FEEDBACK ON WAYS MCHS-CANNON FALLS CAN IMPROVE CUSTOMER SERVICE AND DETERMINE WHETHER OR NOT THERE IS A NEED FOR NEW OR EXPANDED SERVICES. THE DATA FROM THE SURVEY IS REVIEWED AND ANALYZED BY MEMBERS OF QUALITY AND ADMINISTRATION DEPARTMENTS AS WELL AS MCHS-CANNON FALLS EMERGENCY ROOM (ER)/INPATIENT SATISFACTION TEAM, A TEAM DEDICATED TO IMPROVING PATIENT SATISFACTION IN THE ER AND HOSPITAL.THROUGH THESE VARIOUS AVENUES, MCHS-CANNON FALLS STAFF MEMBERS ACROSS MANY DEPARTMENTS STAY CONNECTED WITH THE COMMUNITY TO ASSESS THE HEALTHCARE NEEDS OF CANNON FALLS AND SURROUNDING AREAS. 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: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) IS LOCATED IN CANNON FALLS, MINNESOTA. MCHS-CF SERVES CANNON FALLS AND THE SURROUNDING AREA WITHIN GOODHUE COUNTY. THE MCHS-CF CAMPUS INCLUDES A HOSPITAL LICENSED FOR 21 BEDS WITH 15 CURRENTLY IN SERVICE AND A MULTI-SPECIALTY HOSPITAL-BASED CLINIC SERVING CANNON FALLS.ACCORDING TO THE U.S. CENSUS BUREAU AND THE MINNESOTA COMPASS MOST RECENT DATA: CANNON FALLS IS A RURAL COMMUNITY WITH A POPULATION OF 4,090, GOODHUE COUNTY POPULATION WAS ESTIMATED AT 46,464. THE POPULATION IS 49.2% MALE AND 50.8% FEMALE WITH THE MEDIAN RESIDENT AGE BEING 38.5 YEARS OF AGE. THE ESTIMATED MEDIAN HOUSEHOLD INCOME IN CANNON FALLS WAS $45,500, 8.5% OF RESIDENTS HAVE AN INCOME BELOW THE POVERTY LEVEL. PART VI, LINE 5: THIS FILING ORGANIZATION IS AN AFFILIATE OF 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 CLINIC 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 CLINICS 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 V. CLOSED STAFF MODEL: 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. 0 1 1 0 0 0 0 0 0 AGERTER MD DAVID C DIRECTOR/REGION CEO 0 523301 0 0 0 74291 0 10639 0 15567 0 623798 0 0 ALTRICHTER MD PAUL M DIRECTOR/VICE CHAIR 0 260525 0 0 0 1005 0 36367 0 19387 0 317284 0 0 BERNARD MD MATTHEW E DIRECTOR 0 266195 0 0 0 1714 0 38065 0 20645 0 326619 0 0 PARKS DOUGLAS A DIRECTOR/REGION CAO 0 236962 0 0 0 2137 0 28462 0 21555 0 289116 0 0 WHITED MD BRIAN L DIRECTOR 0 473513 0 0 0 2888 0 49069 0 20562 0 546032 0 0 WITT MD THOMAS J DIRECTOR/CHAIR/CEO 0 425606 0 0 0 48467 0 52327 0 17502 0 543902 0 0 GUDGELL STEPHEN F TREASURER 0 201637 0 0 0 1391 0 8287 0 16048 0 227363 0 0 KOCH MARK B ASSISTANT SECRETARY 0 446213 0 0 0 36983 0 10710 0 12967 0 506873 0 0 PRIEST WILLIAM F SECRETARY 185392 0 100 0 8987 0 29228 0 22458 0 246165 0 0 0 TARASOVITCH JAMES J REGION CFO 0 301807 0 0 0 7337 0 47461 0 19489 0 376094 0 0 CHESTNUT MD JANET S PHYSICIAN 286147 0 125 0 54930 0 56098 0 13520 0 410820 0 0 0 JOHNSTON-FLANDERS MD MEGAN S PHYSICIAN 182874 0 20050 0 41482 0 22959 0 27168 0 294533 0 0 0 NORDAHL MD THOMAS W PHYSICIAN 289554 0 50 0 287594 0 47391 0 19964 0 644553 0 0 0 STRICKER MD ALEXANDER W PHYSICIAN 202020 0 20050 0 52832 0 34038 0 1136 0 310076 0 0 0 TURNA MD TARLOCHAN S PHYSICIAN 301541 0 50 0 263477 0 31687 0 13418 0 610173 0 0 0 CHRISTIAN GLENN P FORMER OFFICER 184708 0 50 0 2723 0 28204 0 14065 0 229750 0 0 0 LOHR MD ROBERT H FORMER OFFICER 0 166916 0 0 0 4602 0 0 0 0 0 171518 0 0 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 4B-C 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 PARTICIPATED IN OR RECEIVED A PAYMENT FROM THE SUPPLEMENTAL RETIREMENT PLAN. AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III). AGERTER M.D., DAVID C. $67,586 BERNARD M.D., MATTHEW E. $ 684 CHESTNUT M.D., JANET S. $15,258 JOHNSTON-FLANDERS M.D., MEGAN S. $ 386 KOCH, MARK B. $33,730 LOHR M.D., ROBERT H. $ 2,605 NORDAHL M.D., THOMAS W. $55,151 STRICKER M.D., ALEXANDER W. $ 670 TARASOVITCH, JAMES J. $ 0 TURNA M.D., TARLOCHAN S. $14,455 WHITED M.D., BRIAN L. $ 0 WITT M.D., THOMAS J. $42,856 UNDER MAYO CLINIC'S ROYALTY SHARING POLICY, INVENTORS, INCLUDING LISTED PERSONS, ARE ENTITLED TO SHARE IN A PORTION OF ROYALTIES RECEIVED BY MAYO INCLUDING INSTANCES WHERE SUCH ROYALTIES ARE IN THE FORM OF EQUITY-BASED INSTRUMENTS SUCH AS STOCK, WARRANTS, OR PARTNERSHIP INTERESTS. THE FOLLOWING INDIVIDUALS PARTICIPATED IN AN EQUITY-BASED COMPENSATION ARRANGEMENT: GUDGELL, STEPHEN F. PART II: COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. RYAN SCHRAMM SON-IN-LAW OF FORMER OFFICER, GLENN CHRISTIAN 103128 EMPLOYMENT 0 PART I, LINE 8: CURRENT YEAR CONTRIBUTIONS AND GRANTS INCLUDED IN CONTRIBUTION AND GRANTS (LINE 8) IS AN EQUITY TRANSFER OF $5,000,000 FROM MAYO CLINIC TO ASSIST WITH THE CONSTRUCTION COSTS OF A NEW MEDICAL CENTER FACILITY. THIS TRANSFER IS A ONE-TIME EVENT. REVENUE LESS EXPENSE FROM OPERATIONS (LINE 19) MAKE UP THE REMAINING $2,917,207 OF THE LINE'S TOTAL $7,917,207. FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUAL(S) IS/ARE EMPLOYED BY A RELATED ORGANIZATION: TARASOVITCH, JAMES J. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL(S) WHO IS/ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: WHITED M.D., BRIAN L., KOCH, MARK B. THE FOLLOWING INDIVIDUAL(S) IS/ARE EMPLOYED BY A RELATED ORGANIZATION: WITT M.D., THOMAS J. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL(S) WHO IS/ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: TARASOVITCH, JAMES J., GUDGELL, STEPHEN F., PARKS, DOUGLAS A., KOCH, MARK B., AGERTER M.D., DAVID C. 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 THE CORPORATION IS MAYO CLINIC. FORM 990, PART VI, SECTION A, LINE 7A THE GOVERNING BODY, THE BOARD OF TRUSTEES, CONSISTS OF NINE PERSONS ELECTED AS FOLLOWS: (A) FOUR COMMUNITY TRUSTEES ELECTED BY THE CANNON FALLS HOSPITAL DISTRICT; (B) CHAIR/CEO AND VICE CHAIR ELECTED BY THE BOARD OF TRUSTEES AND APPROVED BY AND ELECTED BY THE SOLE MEMBER AND THREE MEMBER TRUSTEES ELECTED BY THE SOLE MEMBER; AND (C) THREE MEMBER TRUSTEES ELECTED BY THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE BYLAWS ALSO PROVIDE THE SOLE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS OPERATIONS, CAPITAL, BUDGET, AMENDMENT OF ARTICLES OR BYLAWS AND DEBT DECISIONS. FORM 990, PART VI, SECTION A, LINE 8B THE FILING ORGANIZATION HAS NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE BOARD. 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 REGION CHIEF FINANCIAL OFFICER AND FINANCE DIRECTOR, ALONG WITH SITE 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 SALARIES AND BENEFIT PROGRAMS OF THE CHIEF EXECUTIVE OFFICER (CEO) AND THE CHIEF ADMINISTRATIVE OFFICER (CAO) WERE 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 3,333,620. MANAGEMENT AND GENERAL EXPENSES 2,489,583. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,823,203. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 857,887. MANAGEMENT AND GENERAL EXPENSES 76,158. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 934,045. FORM 990, PART XI, LINE 9: LOSS ON UNCOLLECTIBLE PLEDGES -853. PLEDGE CHANGE -290,712. 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 BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(C)(3) 7 MCHS--CHIPPEWA VALLEY INC 1 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 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 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH P 9360610 GAAP MCHS-ALBERT LEA AND AUSTIN M 2475310 GAAP MCHS-ALBERT LEA AND AUSTIN P 1730600 GAAP MCHS-ALBERT LEA AND AUSTIN R 1737918 GAAP MMSI INC S 1502622 GAAP