2015-11-16T10:03:24-06:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-01-01 411801967 SIBLEY MEDICAL CENTER SIBL 5079642271 601 W CHANDLER STREET ARLINGTON MN 55307 DARLA ANDERSON DIRECTOR OF FINANCE 5079642271 2015-11-16 1 KACIE MCEWEN P01599614 6123764500 2014 2016-02-25 16:41:14Z RIDGEVIEW SIBLEY MEDICAL CENTER DARLA ANDERSON 601 W CHANDLER STREET ARLINGTON MN 55307 23478303 0 X WWW.SIBLEYMEDICAL.ORG X 1948 MN TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. 9 9 2 23 0 0 401 10361622 0 12628554 172 27158 1150 448558 1723 23465892 0 4035226 0 0 0 7286070 0 0 0 442 4882186 442 16203482 1281 7262410 184650 14071533 0 6617064 184650 7454469 X RIDGEVIEW SIBLEY MEDICAL CENTER EXISTS TO ENHANCE THE LIFELONG HEALTH OF PEOPLE IT SERVES WITH A CULTURE THAT NURTURES THE WHOLE PERSON: MIND, BODY, AND SPIRIT. 1 0 14995629 4035226 12628554 LOCATED IN ARLINGTON, MINNESOTA, RIDGEVIEW SIBLEY MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL--PROVIDING URGENT CARE, GENERAL SURGERY, AND 24/7 HOSPITAL AND EMERGENCY SERVICES TO RESIDENTS OF SIBLEY COUNTY AND THE SURROUNDING AREA. RIDGEVIEW SIBLEY ALSO HAS CLINIC LOCATIONS IN ARLINGTON, GAYLORD, HENDERSON AND WINTHROP. IT IS PART OF THE RIDGEVIEW MEDICAL CENTER NETWORK, WHICH ALSO INCLUDES A HOSPITAL IN WACONIA, A MULTITUDE OF PRIMARY AND SPECIALTY CARE CLINICS, EMERGENCY SERVICES AND SPECIALTY PROGRAMS, AND TWO TWELVE MEDICAL CENTER IN CHASKA. EFFECTIVE JANUARY 1, 2014, THE CITY OF ARLINGTON, MINNESOTA (CITY), WHO PREVIOUSLY OWNED AND CONTROLLED THE OPERATIONS OF SIBLEY MEDICAL CENTER, ENTERED INTO A HOSPITAL OPERATING LEASE AGREEMENT WITH RIDGEVIEW MEDICAL CENTER (RMC) AND AS OF THE EFFECTIVE DATE, RMC BECAME THE SOLE CORPORATE MEMBER OF THE ORGANIZATION, WHICH NOW OPERATES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. RIDGEVIEW SIBLEY MEDICAL CENTER BELIEVES EVERYONE DESERVES TOP-QUALITY MEDICAL CARE AND THAT THE PEOPLE OF SIBLEY COUNTY SHOULDN'T HAVE TO TRAVEL FAR TO GET THE LATEST MEDICAL ADVANCEMENTS. IT'S THIS BELIEF THAT DRIVES US TO BRING SPECIALTY CARE TO OUR COMMUNITY. IT'S WHY WE CONSTANTLY PURSUE THE TECHNOLOGIES, RECRUIT THE EXPERTS, AND EXPAND AND IMPROVE FACILITIES THAT MAKE GREAT HEALTH CARE POSSIBLE. 14995629 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 30 0 2 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 MN X DARLA ANDERSON 5079648424 601 WEST CHANDLER ARLINGTON MN 55307 KEVIN LINDSTRAND PRESIDENT 0.50 0.00 X X 1800 0 0 DENNIS SCHULTZ VICE PRESIDENT 0.50 0.00 X X 1200 0 0 LISA PFARR SECRETARY 0.50 0.00 X X 1200 0 0 LYLE RUD TRUSTEE 0.50 0.00 X 1200 0 0 BRENDA PAUTSCH TRUSTEE 0.50 0.00 X 1200 0 0 DEE THOMAS TRUSTEE 0.50 0.00 X 1200 0 0 TIM DOLAN TRUSTEE 0.50 0.00 X 1200 0 0 DAVE WELCH TRUSTEE 0.50 0.00 X 1200 0 0 MIKE WERNER TRUSTEE 0.50 2.00 X 1200 0 0 TODD SANDBERG RSMC ADMINISTRATOR 1.00 49.00 X 0 194640 29416 DARLA ANDERSON DIRECTOR OF FINANCE 1.00 49.00 X 0 73201 22110 11400 267841 51526 0 0 1 0 RIDGEVEIW MEDICAL CENTER 500 S MAPLE ST WACONIA MN 55387 MANAGEMENT SERVICES 7564000 PREMIER STAFFING INC 243 WINKLER TRAIL COLOGNE MN 55322 NURSING SERVICES 399328 CPSI 6600 WALL STREET MOBILE AL 36695 IT SERVICES 334117 CMDI 150 10TH STREET NW MILACA MN 56353 IMAGING SERVICES 107463 4 12241 10349381 6413763 10361622 NET PATIENT REVENUE 621300 12628554 12628554 12628554 20958 20958 80457 0 80457 80457 80457 6200 0 6200 6200 6200 22513 12241 9787 12726 12726 4423 2624 1799 1799 MEANINGFUL USE INCOME 900099 253409 253409 JOINT VENTURE INCOME 900099 39517 39517 FINANCE CHARGE 900099 39141 39141 21509 21509 353576 23465892 12628554 0 475716 4035226 4035226 6113950 5496036 617914 199801 190315 9486 580589 521911 58678 391730 369193 22537 3638 3638 15020 15020 66265 66265 1501314 1496405 4909 39136 39136 146123 96543 49580 174666 174666 262524 262524 56989 51960 5029 40668 35641 5027 180529 180529 206527 186624 19903 15266 15266 MEDICAL SUPPLIES 1438430 1438430 0 BAD DEBT EXPENSE 220149 220149 MINNESOTA CARE TAX 166133 166133 OTHER 118599 52766 65833 230210 195244 34966 16203482 14995629 1207853 0 184650 3831917 744090 2489485 11290 280006 62302 5620152 206528 0 5413624 1010163 228656 184650 14071533 345738 333062 4618324 0 1319940 0 6617064 X 184650 7454469 184650 7454469 184650 14071533 7262410 7409 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4852887 161545 4691342 113451 113451 354563 44983 309580 299251 299251 5413624 THIRD PARTY PAYOR SETTLEMENTS 391000 RELATED PARTY PAYABLE 928940 1319940 X 12981587 -220149 -220149 13201736 10264156 10264156 23465892 11961183 12411 12411 11948772 4254710 4254710 16203482 PART X, LINE 2: THE ORGANIZATION HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT FOR UNCERTAIN TAX POSITIONS. THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATION UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -220,149. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 20,958. SPECIAL EVENT EXPENSES -9,787. TRANSFER FROM SIBLEY MEDICAL CENTER (CITY OWNED) 10,255,609. COST OF GOODS SOLD -2,624. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 9,787. COST OF GOODS SOLD 2,624. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 220,149. TRASNFER TO CITY OF ARLINGTON, MN 4,034,561. SPRING BENEFIT 18751 9241 9510 50 295 360 2352 500 208 FISH HOUSE RAFFLE 12280 3000 9280 5811 0 0 0 0 210 31031 12241 18790 5861 295 360 2352 500 418 9786 9004 1 1 X 1 X 1 X 225.000000000000 1 1 0 0 142864 142864 0.00890 349023 225590 123433 0.00770 491887 225590 266297 0.01660 28501 6078 22423 0.00140 6000 6000 0.00040 1142264 1111769 30495 0.00190 1176765 1117847 58918 0.00370 1668652 1343437 325215 0.02030 1 220149 0 5531128 5506803 24325 X 1 1 1 1 RIDGEVIEW SIBLEY MEDICAL CENTER 601 WEST CHANDLER STREET ARLINGTON MN 55307 WWW.SIBLEYMEDICAL.ORG HFID-00618 X X X X RIDGEVIEW SIBLEY MEDICAL CENTER 1 0 1 1 X X X X X X X X X 13 1 0 1 1 X WWW.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT X 1 13 1 WWW.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT 0 0 1 X 150.000000000000 225.000000000000 X 0 1 X X 0 1 0 X X X 1 X 0 0 RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 5: IN ORDER TO ENSURE THE REVIEW OF THE RESEARCH WAS QUALITY DATA, COMMUNITY LEADERSHIP TEAM (CLT) INITIATED, PLANNED AND IMPLEMENTED THE PROJECT. PERSONNEL THAT PARTICIPATED REPRESENT A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL SERVICES, NON-PROFIT AND SOCIAL ORGANIZATIONS, AND THE BUSINESS COMMUNITY. TWO FOCUS GROUPS WERE FORMED THAT REPRESENTED A TOTAL OF 35 KEY COMMUNITY LEADERS IN MAY AND JUNE OF 2013. THE ASSESSMENT INITIATIVE WAS CONDUCTED IN TWO DISTINCT PHASES. INITIALLY, PHONE CONFERENCES WERE HELD WITH A CONSULTANT FROM STRATUS HEALTH TO DETERMINE HOW TO GATHER KEY STAKEHOLDERS INPUT AND INFORMATION. BETWEEN THE LOCAL PUBLIC HEALTH STAFF AND THE HOSPITAL STAFF, IT WAS DECIDED TO CONDUCT COMMUNITY FOCUS GROUPS. THROUGH COLLABORATION, A LIST OF KEY STAKEHOLDERS WAS DEVELOPED AND INVITATIONS WERE SENT OUT TO THE COMMUNITY. APPROXIMATELY 100 PEOPLE WERE SELECTED TO PARTICIPATE IN THE FOCUS GROUPS. THE SELECTION OF THE PERSONNEL ASKED TO PARTICIPATE WAS BASED ON: - PERSONS WITH SPECIAL KNOWLEDGE OR EXPERTISE IN PUBLIC HEALTH - REPRESENTATIVES FROM HEALTH DEPARTMENTS OR GOVERNMENT AGENCIES SERVING COMMUNITY HEALTH - LEADERS OR MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE - OTHER KEY STAKEHOLDERS IN THE COMMUNITYINVITATIONS WERE SENT BY MAIL AND E-MAIL WITH A REQUEST TO RESPOND FOR ATTENDANCE. OUR RECOMMENDATION WAS TO MEET FOR TWO SESSIONS AND ASSESS THE HEALTH NEEDS OF OUR COMMUNITY. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 2: EFFECTIVE JANUARY 1, 2014, THE CITY OF ARLINGTON, MINNESOTA, WHO PREVIOUSLY OWNED AND CONTROLLED THE OPERATIONS OF SIBLEY MEDICAL CENTER, ENTERED INTO A HOSPITAL LEASE OPERATING AGREEMENT WITH RIDGEVIEW MEDICAL CENTER (RMC) AND AS OF THE EFFECTIVE DATE, RMC BECAME THE SOLE CORPORATE MEMBER OF THE ORGANIZATION, WHICH NOW OPERATES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 11: UPON REVIEWING THE TOP TEN LEADING HEALTH CARE INDICATORS, A LIST OF CRITERIA WAS CREATED TO ASSIST ASSESSING THE AREAS MOST NEEDING IMPROVEMENT IN OUR COMMUNITY. THE GOAL WAS TO THEN DETERMINE THE TOP THREE TOPICS FOR DEVELOPING PLANS TO IMPLEMENT CHANGE IN THE COMMUNITY.DECISION MAKING CRITERIA: - AFFORDABILITY - CAN WE MAKE AN IMPACT - IS THERE SUPPORT ALREADY IN PLACE - MULTIPLE IMPACT POINTS/OVERLAP WITH MULTIPLE AREAS - SUSTAINABILITY - IS IT REALISTIC - WITH WHOM CAN WE COLLABORATE FOR A BIGGER IMPACT - IS THE COMMUNITY READY TO ENGAGE - AWARENESS OF WHAT IS CHANGING BEYOND 3 YEARS - SUPPORT OF LEADERSHIP - LEGISLATIVE/COUNTY COMMISSIONER SUPPORT - DATA/ABILITY TO MEASURE CHANGEAFTER ANALYZING THE TEN TOPICS WITH THE DECISION MAKING CRITERIA, THE FOCUS GROUP INDIVIDUALS VOTED FOR THEIR TOP THREE TOPICS. THE FOLLOWING HAD THE MAJORITY OF THE VOTES AND WILL BE THE FOCUS OF SIBLEY MEDICAL CENTER'S COMMUNITY HEALTH NEEDS ASSESSMENT: OBESITY, MENTAL HEALTH, AND PREVENTION AND WELLNESS. SIBLEY MEDICAL CENTER PLANS TO FOCUS ON THE FOLLOWING ISSUES IDENTIFIED THOUGH THE COMMUNITY HEALTH NEEDS ASSESSMENT. THESE PRIORITY AREAS WILL BE ADDRESSED BY CONTINUING TO STRENGTHEN EXISTING SIBLEY MEDICAL CENTER PARTNERSHIPS, AS WELL AS BY ATTEMPTING TO REACH MORE INDIVIDUALS THAT WOULD BE INTERESTED IN CONTRIBUTING IN THE COMMUNITY.AFTER COMPLETING THE FOCUS GROUPS AND MEETING WITH THE COMMUNITY TO IDENTIFY HEALTH PRIORITIES, THE COMMUNITY LEADERSHIP TEAM (CLT) IS TO HELP CONTINUE TO MAKE PROGRESS ON THESE PRIORITIES. CLT IS COMPRISED OF A VARIETY OF INDIVIDUALS IN A THREE COUNTY-WIDE SPREAD. PERSONNEL INCLUDE: PUBLIC HEALTH, LOCAL BUSINESSES, COALITIONS, CITY PERSONNEL AND HOSPITALS. THE COMMUNITY LEADERSHIP TEAM HAS BEEN WORKING ON COUNTY HEALTH INITIATIVES SINCE 2009. NOW, THE TEAM WILL BE INVOLVED IN PLANNING AND IMPLEMENTING CHANGES IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT.WHEN THE TEAM MET IN JUNE AND JULY, THEY DERIVED A PLAN TO CREATE THREE SUBCOMMITTEES, WHICH WILL ADDRESS THE HEALTH PRIORITIES. THE SUB COMMITTEES ARE AS FOLLOWS: MEEKER-MCLEOD-SIBLEY HEALTH COMMUNITIES COLLABORATIVE (DISEASE PREVENTION AND WELLNESS, MENTAL HEALTH, AND HEALTHY BEHAVIORS. IN AUGUST 2013, THE CLT COMMITTEE MET AND BEGAN ASSIGNING PERSONNEL TO EACH COMMITTEE. THE COMMITTEES WILL MEET QUARTERLY TO IDENTIFY, DEVELOP AND IMPLEMENT A STRATEGIC PLAN TO ADDRESS EACH OF THESE TOPICS. THE PROGRESS REPORTS FROM EACH COMMITTEE WILL BE SHARED WITH THE CLT COMMITTEE TO ENSURE BOTH PROGRESS IS BEING MADE AND THE WORK EACH COMMITTEE IS COMPLETING IS NOT BEING DUPLICATED IN ANOTHER COMMITTEE. RIDGEVIEW SIBLEY MEDICAL CENTER PART V, SECTION B, LINE 22D: EVERY SELF-PAY PATIENT GETS A DISCOUNT EQUAL TO THE GREATEST COMMERCIAL PAYOR. UPON DETERMINATION OF A PATIENT'S CHARITY CARE ELIGIBLITY, SIBLEY MEDICAL CENTER, REVERSES THE ORIGINAL SELF-PAY DISCOUNT GIVEN AND AT A MINIMUM IS GIVEN 25% DISCOUNT ON THEIR BILL WHICH IS GREATER THAN THE DISCOUNT GIVEN TO ALL SELF-PAY AND COMMERCIALLY INSURED PATIENTS. 4 RIDGEVIEW ARLINGTON CLINIC 601 WEST CHANDLER STREET ARLINGTON MN 55307 CLINIC RIDGEVIEW GAYLORD CLINIC 660 3RD STREET GAYLORD MN 55334 CLINIC RIDGEVIEW HENDERSON CLINIC 505 MAIN STREET HENDERSON MN 56044 CLINIC RIDGEVIEW WINTHROP CLINIC 223 NORTH CARVER STREET WINTHROP MN 55396 CLINIC PART I, LINE 3C: ELIGIBILITY FOR SIBLEY MEDICAL CENTER'S CHARITY CARE PROGRAM IS BASED ON FAMILY INCOME RELATIVE TO FEDERAL POVERTY GUIDELINES (FPG). FREE CARE IS OFFERED FOR FEDERAL ADJUSTED GROSS INCOME UP TO 150% OF FPG. 75% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 175% OF FPG. 50% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 200% OF FPG. AND 25% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 225% OF FPG. PART I, LINE 7: THE COSTING METHODOLOGY USED BY SIBLEY MEDICAL CENTER TO DETERMINE THE COMMUNITY BENEFIT EXPENSES INCLUDED IN PART I, LINES 7A-D WERE DERIVED BY TAKING THE RESPECTIVE AMOUNTS PER THE AUDITED FINANCIAL STATEMENTS AND APPLYING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. THE COMMUNITY BENEFIT EXPENSES INCLUDED IN LINES 7E-J WERE REPORTED BASED ON SMC'S ACTUAL COSTS FOR EACH CLASSIFICATION OF EXPENSES. PART I, LN 7 COL(F): BAD DEBT EXPENSES INCLUDED ON FORM 990, PART IX, LINE 24, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $220,149 FOR THE YEAR ENDED DECEMBER 31, 2014. PART III, LINE 4: THE NOTE OF SIBLEY MEDICAL CENTER'S 2014 FINANCIAL STATEMENTS THAT INCLUDES THE EXPLANATION OF BAD DEBT EXPENSE IS THE "PATIENT RECEIVABLES, NET" FOOTNOTE INCLUDED ON PAGE 8. PART III, LINE 8: SIBLEY MEDICAL CENTER USED THE 2014 FILED MEDICARE COST REPORT TO CALCULATE THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6. THERE WAS NO MEDICARE SHORTFALL CALCULATED IN PART III, LINE 7 FOR THE YEAR ENDED DECEMBER 31, 2014. PART III, LINE 9B: AT ANY POINT DURING THE BILLING AND COLLECTION PROCESS A PATIENT HAS THE ABILITY TO REQUEST AN APPLICATION FOR FINANCIAL ASSISTANCE. ONCE AN APPLICATION HAS BEEN REQUESTED, THE COLLECTION PROCESS PAUSES AND DOES NOT CONTINUE UNTIL A DETERMINATION IS MADE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: IN 2013, SIBLEY MEDICAL CENTER PARTNERED WITH NEIGHBORING COMMUNITIES, PUBLIC HEALTH DEPARTMENTS AND STRATIS HEALTH (AN INDEPENDENT, NONPROFIT ORGANIZATION THAT LEADS IN COLLABORATION AND INNOVATION IN HEALTH CARE QUALITY AND SAFETY) TO COMPLETE THE INITIAL DISCOVERY PHASE OF THE ASSESSMENT. THE LEAD CONSULTANT, KIM MCCOY WITH STRATIS HEALTH, FACILITATED THE INITIAL PHASE OF CONDUCTING A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT. THE OVERALL GOAL OF THE ASSESSMENT WAS TO IDENTIFY THE MAJOR HEALTH NEEDS, SERVICE GAPS, BARRIERS TO ACCESS, AND HEALTH PRIORITIES FOR THE COMMUNITY. AS PART OF THE ASSESSMENT, STRATUS HEALTH COLLECTED QUANTITATIVE AND QUALITATIVE INFORMATION FROM A BROAD ARRAY OF SOURCES. THE PURPOSE OF GATHERING THE INFORMATION AND STATISTICS WAS TO ANALYZE THE HEALTH OF THE COMMUNITY AND THEN FACILITATE THE DEVELOPMENT OF SHORT AND LONG-TERM PLANS TO GUIDE THE HEALTH INVESTMENTS OF SIBLEY COUNTY. PART VI, LINE 4: SIBLEY COUNTY INCLUDES SEVEN CITIES. IN AGGREGATE, THE LAND SIZE IS 600.41 SQUARE MILES WITH A TOTAL POPULATION OF 15,123 PEOPLE. SIBLEY COUNTY IS CONSIDERED A "FRINGE" COUNTY AND IS ON THE WESTERN BOUNDARY OF THE SEVEN-COUNTY TWIN CITIES METROPOLITAN AREA. THE DISTINCT QUALITIES OF EACH COMMUNITY PROVIDE A UNIQUE BLEND OF HISTORY AND CULTURE. MANY COMMUTERS TAKE ADVANTAGE OF OUR LOWER HOUSING COSTS AND THE BENEFITS OF RURAL LIVING.AGRICULTURE IN SIBLEY COUNTY IS A MAIN SOURCE OF EMPLOYMENT AND INCOME. THERE ARE 352,000 ACRES DEDICATED TO FARMING. OF THESE FARMS, 86.55% OF THEM ARE INDIVIDUALLY / FAMILY OWNED AND OPERATED. THE AVERAGE VALUE OF THE AGRICULTURAL PRODUCTS SOLD PER FARM IS $175,079. ALONG WITH THE PRODUCTION OF CROPS, A LARGE NUMBER OF FARMS RAISE LIVESTOCK, POULTRY, AND DAIRY CATTLE.ACCORDING TO THE 2010 US CENSUS, THERE ARE 15,123 PEOPLE LIVING IN SIBLEY COUNTY, WITH THE MAJORITY OF THE POPULATION RESIDING IN THE CITIES OF ARLINGTON, GAYLORD, AND WINTHROP. THE POPULATION BREAKDOWN SHOWS THOSE UNDER 18 YEARS OF AGE AT 24.7%, THOSE 65 YEARS AND OVER AT 16.9%; WITH THE MEDIAN RESIDENT AGE AT 40.0 YEARS. THE POPULATION DECREASED -0.7% SINCE 2010, BUT OVERALL THE POPULATION HAS STAYED CONSISTENT OVER THE LAST DECADE. 1 CITY OF ARLINGTON MN 204 SHAMROCK DRIVE ARLINGTON MN 55307 416004941 115 4034561 NET BOOK VALUE BUILDINGS AND TAX EXEMPT BONDS THE HOSPITAL TRANSFERRED THE HOSPITAL FACILITY AND TAX EXEMPT BONDS TO THE CITY OF ARLINGTON, MN UNDER THE TERMS OF A LEASE AGREEMENT WITH THE CITY. 1 0 PART I, LINE 2: THE TRANSFER OF NET ASSETS TO THE CITY WAS A RESULT OF A LEASE AGREEMENT BETWEEN THE HOSPITAL AND THE CITY. THE ONGOING RELATIONSHIP BETWEEN THE PARTIES WILL SERVE AS THE PROCEDURES TO MONITOR THE USE OF THE ASSETS. 0 0 0 0 0 0 0 0 0 TODD SANDBERG RSMC ADMINISTRATOR 0 164568 0 29530 0 542 0 7717 0 21699 0 224056 0 224056 X 1 1695019 FMV X 1 272939 FMV X 1 6787706 FMV X 1 278366 FMV X ACCOUNTS/NOTES RECEIVABLE 1 2110601 FMV X PREPAID EXPENSES/OTHER ASSETS 1 120362 FMV X LIABILITIES 1 -4666580 FMV 0 0 0 FORM 990, PART III, LINE 2 EFFECTIVE JANUARY 1, 2014, THE CITY OF ARLINGTON, MINNESOTA (CITY), WHO PREVIOUSLY OWNED AND CONTROLLED THE OPERATIONS OF SIBLEY MEDICAL CENTER, ENTERED INTO A HOSPITAL OPERATING LEASE AGREEMENT WITH RIDGEVIEW MEDICAL CENTER (RMC) AND AS OF THE EFFECTIVE DATE, RMC BECAME THE SOLE CORPORATE MEMBER OF THE ORGANIZATION, WHICH NOW OPERATES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. UNDER THE TERMS OF THE LEASE AGREEMENT, THE CITY TRANSFERRED ALL ASSETS AND LIABILITIES, EXCEPT THE MAJORITY OF THE CAPITAL ASSETS (FACILITY) AND THE SERIES 2010B BONDS, TO THE ORGANIZATION. AS OF THE EFFECTIVE DATE, ALL EMPLOYEES OF THE SIBLEY MEDICAL CENTER (PREVIOUSLY OWNED BY THE CITY) BECAME EMPLOYEES OF RMC OR ITS AFFILIATES. ON THE EFFECTIVE DATE, THE ORGANIZATION ENTERED INTO A MANAGEMENT SERVICES AGREEMENT WITH RMC. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS A MANAGEMENT SERVICE AGREEMENT WITH RIDGEVIEW MEDICAL CENTER TO PROVIDE PHYSICIAN, ADMINISTRATIVE, INFORMATION TECHNOLOGY, HUMAN RESOURCES, LAUNDRY, DIETICIAN AND OTHER SERVICES. THE ORGANZATION PURCHASED APPROXIMATELY $7,564,000 IN SERVICES FROM RIDGEVIEW FOR THE YEAR ENDED DECEMBER 31, 2014. FORM 990, PART VI, SECTION A, LINE 4 SIGNIFICANT CHANGES MADE TO SIBLEY MEDICAL CENTER'S GOVERNING DOCUMENTS ARE AS FOLLOWS: 1. NAME CHANGE FROM SIBLEY MEDICAL CENTER FOUNDATION TO SIBLEY MEDICAL CENTER. THE IRS WAS ALREADY NOTIFIED OF THIS CHANGE SO THERE WASN'T A NEED TO CHECK THE BOX ON PAGE 1 OF THE RETURN. 2. SMC'S PURPOSE AND MISSION. 3. RIDGEVIEW MEDICAL CENTER SHALL BE THE SOLE MEMBER OF SIBLEY MEDICAL CENTER, AS SUCH THEY HAVE CERTAIN RIGHTS IDENTIFIED IN THE GOVERNING DOCUMENTS. 4. THE NUMBER OF, ELECTION OF, AND TERMS OF SMC'S BOARD OF DIRECTORS ALL CHANGED. 5. THE AUTHORITY TO AMEND THE GOVERNING DOCUMENTS. FORM 990, PART VI, SECTION A, LINE 6 RIDGEVIEW MEDICAL CENTER SHALL BE THE SOLE MEMBER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A AT ALL TIMES THERE WILL ALWAYS BE A DIRECTOR WHO IS APPOINTED BY THE MEMBER AND WHO SITS ON THE BOARD OF DIRECTORS OF THE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE BOARD OF DIRECTORS WILL CARRY OUT THE DUTIES NORMALLY ASSOCIATED WITH A NONPROFIT HOSPITAL BOARD OF DIRECTORS, SUBJECT TO THE RESERVED POWERS OF THE MEMBER AND THE CITY BELOW. THE MEMBER RESERVED AUTHORITY WITH REGARD TO THE MATTERS LISTED BELOW, SUBJECT TO THE RESERVED POWERS OF THE CITY INCLUDED THEREAFTER. THE MEMBER WILL LOOK TO THE BOARD TO MAKE RECOMMENDATIONS ON DECISIONS ON MATTERS LISTED BELOW, BUT THE MEMBER IS NOT REQUIRED TO ACCEPT SUCH RECOMMENDATIONS, AND THE MEMBER MAY TAKE ACTION ON ITS OWN IN SUCH AREAS, SUBJECT TO THE CITY'S RESERVED POWERS. THE MEMBER'S APPROVAL WILL BE REQUIRED FOR ANY ACTION PROPOSED BY THE BOARD IN THESE AREAS: (I) FINAL APPOINTMENT OF BOARD MEMBERS (II) ISSUANCE OF DEBT BY THE CORPORATION (III) SALE OF SUBSTANTIAL ASSETS OF THE CORPORATION (IV) CHANGES IN THE CORPORATION'S ARTICLES OF INCORPORATION AND BYLAWS (V) ESTABLISHMENT OF ANOTHER MEMBER RELATIONSHIP BY THE CORPORATION OR ANOTHER FORM OF AFFILIATION (VI) STRATEGIC PLAN FOR THE CORPORATION (VII) OPERATING AND CAPITAL BUDGETS OF THE CORPORATION (VIII) UNBUDGETED TOTAL ANNUAL CAPITAL EXPENDITURES (IX) AUDIT AND COMPLIANCE PROGRAMS (X) ACCREDITATION PROGRAMS (XI) GROUP EMPLOYEE BENEFITS (XII) MANAGING THE CORPORATION'S CASH AND INVESTMENTS (THE MEMBER MAY MOVE FUNDS BETWEEN THE ORGANIZATIONS FREELY, SUBJECT TO BOND COVENANT OR TRUSTEE REQUIREMENTS) (XIII) THIRD PARTY PAYER CONTRACTING (XIV) INSURANCE (XV) INFORMATION SYSTEM DESIGN AND IMPLEMENTATION (XVI) GROUP PURCHASING THE CITY'S APPROVAL WILL BE REQUIRED FOR THE DECISIONS OF THE BOARD IN THE FOLLOWING AREAS: (I) SALE OF ALL OR SUBSTANTIALLY ALL OF THE CORPORATION'S ASSETS (II) SALE OF ASSETS ABOVE THRESHOLDS ALLOWED BY BOND COVENANTS (III) ISSUANCE OF DEBT WHICH WOULD OBLIGATE THE CORPORATION IN EXCESS OF LEVELS ALLOWED BY BOND COVENANTS (IV) CHANGES TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS FORM 990, PART VI, SECTION B, LINE 11 THE MANAGEMENT TEAM REVIEWS THE FORM 990 IN DETAIL. ONCE APPROVED A COPY OF THE FORM 990 IS THEN PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING WIT THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ANNUALLY REVIEW AND SIGN THE STATEMENTS FOR POTENTIAL CONFLICTS OF INTEREST POLICY. EACH MEMBER IS EXPECTED TO DISCLOSE ANY CONFLICT OF INTEREST THAT MAY ARISE DURING THE YEAR. IF IT IS DETERMINED THAT A CONFLICT OF INTEREST EXISTS, THE SITUATION WILL BE EXAMINED AND HANDLED APPROPRIATELY BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. RIDGEVIEW FOUNDATION 500 SOUTH MAPLE STREET WACONIA MN 55387 411328097 RAISING FUNDS FOR RIDGEVIEW MEDICAL CENTER MN 501(3)(C) LINE 7 RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 HEALTH CARE SERVICES MN 501(3)(C) LINE 3 N/A 0 RIDGEVIEW INSURANCE COMPANY 60 E SOUTH TEMPLE STE 1800 SALT LAKE CITY UT 84111 454109041 CAPTIVE INSURANCE COMPANY UT 501(3)(C) LINE 11A, I RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW CLINICS 500 SOUTH MAPLE STREET WACONIA MN 55387 411651783 HEALTH CARE SERVICES MN 501(3)(C) LINE 3 RIDGEVIEW MEDICAL CENTER 0 MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER LLC 500 SOUTH MAPLE STREET WACONIA MN 55387 205785920 CARDIOLOGY SERVICES MN N/A CHASKA PLAZA SURGERY CENTER 3000 HUNDERTMARK ROAD CHASKA MN 55318 450975783 SURGERY SERVICES MN N/A EXECUTIVE HEALTH MANAGEMENT SERVICES INC 500 SOUTH MAPLE STREET WACONIA MN 55387 411760239 MANAGEMENT SERVICES MN N/A C 0 CHARITABLE REMAINDER UNITRUST (1) CHARITABLE TRUST MN N/A T 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 0