2015-10-14T12:18:58-05:00 2014-03-31 420714325 MCGLADREY LLP 227 W FIRST ST STE 700 DULUTH MN 558021926 990 2013-04-01 411724637 LONGVILLE LAKES CLINIC INC LONG 2185464366 PO BOX 148 LONGVILLE MN 56655 KYLE BAUER CFO 2185464366 2015-09-21 1 JULIE BOYER P01278549 2187275025 2013 2016-02-25 16:41:14Z X X KYLE BAUER PO BOX 148 LONGVILLE MN 56655 725750 0 X WWW.CUYUNAMED.ORG X 1992 MN TO BRING A HIGHER LEVEL OF HEALTH CARE CLOSER TO HOME, CARE THAT REFLECTS THE COMMUNITY PROVIDING IT. 18 18 10 20 0 0 31546 43589 510135 682161 96 0 0 0 541777 725750 0 0 0 0 320741 301971 0 0 0 499495 563139 820236 865110 -278459 -139360 264541 238872 161978 275669 102563 -36797 TO PROVIDE COMPREHENSIVE, EXCELLENT MEDICAL CARE TO LONGVILLE AREA RESIDENTS. 0 0 807054 682161 THE CARE TEAM AT LONGVILLE LAKES CLINIC PROVIDES A WIDE RANGE OF FAMILY MEDICINE FROM PREVENTATIVE HEALTH SERVICES TO CHRONIC DISEASE MANAGEMENT. IN A STYLE THAT , MORE THAN EVER, REFLECTS LONGVILLE'S UNIQUE SENSE OF COMMUNITY. THE CLINIC IS AVAILABLE FIVE DAYS A WEEK WITH SOME EXTENDED EVENING HOURS.LONGVILLE LAKES CLINIC PROVIDES THE COMMUNITY WITH A VARIETY OF ADVANCED TREATMENTS AND SUPPORT, AND THROUGH ITS PARTNERSHIP WITH CUYUNA REGIONAL MEDICAL CENTER AND ITS AFFILIATES HAS NUMEROUS REFERRAL OPTIONS TO MEET MORE SOPHISTICATED MEDICAL NEEDS.ON MARCH 28, 2010, THE CLINIC BECAME A CERTIFIED RURAL HEALTH CLINIC. 807054 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 10 1 0 0 0 0 0 0 0 0 0 0 X 18 18 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 MN X KYLE BAUER 2185467000 320 EAST MAIN ST CROSBY MN 56441 EARL W BEDARD CLERK 0.10 1.10 X X 0 6575 0 MYRON MIDTHUN TREASURER 0.10 1.10 X X 0 3800 0 THEODORA SKATTUM DIRECTOR 0.10 0.60 X 0 1900 0 ROGER TWIGG CHAIRMAN 0.10 1.10 X X 0 4800 0 RUTH HANSEN DIRECTOR 0.10 0.60 X 0 1775 0 DANNO MAHONEY DIRECTOR 0.10 0.60 X 0 1000 0 MARY ZILLMER DIRECTOR 0.10 0.90 X 0 2200 0 MIKE VANHORN DIRECTOR 0.10 0.60 X 0 1700 0 BETTY PLATISHA DIRECTOR 0.10 0.60 X 0 770 0 ANDREA BEDARD DIRECTOR 0.10 0.90 X 0 2000 0 HARRY GOTTSCH VICE CHAIR 0.10 1.10 X X 0 3400 0 BRIAN DOBSON DIRECTOR 0.10 0.60 X 0 2000 0 MARY LOU SWENSON DIRECTOR 0.10 0.60 X 0 0 0 AL EBNET DIRECTOR 0.10 0.90 X 0 1500 0 DAVE KAUPHUSMAN DIRECTOR 0.10 0.60 X 0 2200 0 FLOYD HALE DIRECTOR 0.10 0.90 X 0 2500 0 RICHARD SCHILLER DIRECTOR 0.10 0.60 X 0 2400 0 KATHY PIERSON DIRECTOR 0.10 0.60 X 0 1200 0 NANCY MORITZ DIRECTOR 0.10 0.60 X 0 2200 0 JOLIENNE LUNDQUIST DIRECTOR 0.10 0.60 X 0 2700 0 KYLE BAUER CFO 3.00 37.00 X 0 192089 15860 THERESA SULLIVAN CEO 5.00 35.00 X 0 152037 13399 JOHN SOLHEIM CEO 1.00 39.00 X 0 346907 19919 AMY HART COO 5.00 35.00 X 0 111306 2787 DR MARK W GUJER ANESTHESIOLOGIST 0.00 40.00 X 0 611344 19919 DR FAWN W ATCHISON ANESTHESIOLOGIST 0.00 40.00 X 0 444709 18085 EILEEN M KURPIERS CRNA 0.00 40.00 X 0 222670 17895 MICHAEL K MCCORMICK CRNA 0.00 40.00 X 0 204338 14450 RODNEY S OGARD CRNA 0.00 40.00 X 0 202171 16827 0 2534191 139141 0 0 1 0 CENTRAL LAKES PHYSICIANS PA 318 E MAIN STREET CROSBY MN 56441 PHYSICIAN SERVICES 209927 1 43589 43589 PATIENT REVENUE 621500 682161 682161 682161 725750 682161 0 0 X 243525 243525 7215 7215 34746 34746 16485 16485 411672 360816 50856 60117 60117 38586 31386 7200 11604 11604 22070 22070 5359 5359 PROVISION FOR DOUBTFUL 6360 6360 DUES & SUBSCRIPTIONS 3735 3735 MINNESOTA CARE TAX 3636 3636 865110 807054 58056 0 24008 51593 76341 39228 7685 0 2333 3059 374737 229745 154174 144992 264541 238872 33428 20462 128550 255207 161978 275669 X 102563 -36797 102563 -36797 264541 238872 -139360 0 X 0 1 X 1 0 X 25131 12442 21525 31546 43589 134233 470924 451493 521421 510135 682161 2636134 496055 463935 542946 541681 725750 2770367 0 0 0 2770367 83 59 78 96 316 83 59 78 96 316 496138 463994 543024 541777 725750 2770683 0.99990 0.99980 0.00010 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 374737 229745 144992 144992 DUE TO CUYUNA RANGE HOSPITAL DISTRICT 255207 255207 0 0 0 0 0 0 0 0 0 KYLE BAUER CFO 0 192089 0 0 0 0 0 10020 0 5840 0 207949 0 0 THERESA SULLIVAN CEO 0 152037 0 0 0 0 0 7950 0 5449 0 165436 0 0 JOHN SOLHEIM CEO 0 346907 0 0 0 0 0 12750 0 7169 0 366826 0 0 DR MARK W GUJER ANESTHESIOLOGIST 0 611344 0 0 0 0 0 12750 0 7169 0 631263 0 0 DR FAWN W ATCHISON ANESTHESIOLOGIST 0 444709 0 0 0 0 0 12750 0 5335 0 462794 0 0 EILEEN M KURPIERS CRNA 0 222670 0 0 0 0 0 11565 0 6330 0 240565 0 0 MICHAEL K MCCORMICK CRNA 0 204338 0 0 0 0 0 8120 0 6330 0 218788 0 0 RODNEY S OGARD CRNA 0 202171 0 0 0 0 0 10497 0 6330 0 218998 0 0 JANEL KAUPSHMAN WIFE OF DAVID KAUPSHMAN, DIRECTOR 84416 EMPLOYMENT 0 BOBBIE MIDTHUN DAUGHTER IN LAW OF MYRON MIDTHRUN, DIRECTOR 43569 EMPLOYMENT 0 CARLA CARLSON SISTER IN LAW OF ANDREA BEDARD, DIRECTOR 32431 EMPLOYMENT 0 WENDY MULL DAUGHTER OF ALICE TEDDY SKATTUM, DIRECTOR 31111 EMPLOYMENT 0 FORM 990, PAGE 1 , HEADING PART B EXPLANATION OF AMENDED 2013 RETURN: THIS RETURN IS BEING AMENDED TO INCLUDE ADDITIONAL REVENUE AND EXPENSE ACCOUNTS WHICH WERE INADVERTENTLY LEFT OUT OF THE ORIGINALLY FILED RETURN. ADDITIONALL, PART VII INCLUDES COMPENSATION INFORMATION FOR THE FIVE HIGHEST PAID EMPLOYEES, WHO WERE COMPENSATED FROM A RELATED TAX EXEMPT ENTITY. THE FOLLOWING LINES ITEMS CHANGED DUE TO THE CHANGES ABOVE: - FORM 990, PART I, LINES 9, 15, 18, 19, 21, AND 22 - FORM 990, PART VIII, LINES 2A AND 12 - FORM 990, PART IX - FORM 990, PART X, LINES 25, 27, AND 33 - FORM 990, PART XI, LINES 1, 2, 3, AND 10 - SCHEDULE A, PART III, LINES 2, 8, 13, AND 15 - FORM 990, PART VII, SECTION A - SCHEDULE J, PART II FORM 990, PART VI, SECTION A, LINE 6 CUYUNA RANGE HEALTH CORPORATION IS THE SOLE MEMBER OF LONGVILLE LAKES CLINIC. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS CONSISTS OF EIGHTEEN DIRECTORS WHO ARE DESIGNATED BY CUYUNA RANGE HEALTH CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE COMMITTEE REVIEWS THE FORM 990 AND SUGGESTS APPROVAL TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C 1. DUTY TO DISCLOSE: IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. 2. DETERMINING WHETHER A CONFLICT OF INTEREST EXISTS: AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BY MAJORITY VOTE. 3. PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST: A. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE GOVERNING BOARD OR COMMITTEE MEETING, BUT AFTER THE PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. B. THE CHAIRPERSON OF THE GOVERNING BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. C. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE ORGANIZATION CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. D. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY UNANIMOUS VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE ORGANIZATION'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION IT SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. 4. VIOLATIONS OF THE CONFLICTS OF INTEREST POLICY: A. IF THE GOVERNING BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. B. IF, AFTER HEARING THE MEMBER'S RESPONSE AND AFTER MAKING FURTHER INVESTIGATION AS WARRANTED BY THE CIRCUMSTANCES, THE GOVERNING BOARD OR COMMITTEE DETERMINES THE MEMBER HAS FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. RECORDS OF PRECEDINGS: THE MINUTES OF THE GOVERNING BOARD AND ALL COMMITTEES WITH BOARD DELEGATED POWERS SHALL CONTAIN: 1. THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE GOVERNING BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED. 2. THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION WITH THE PROCEEDINGS. COMPENSATION: 1. A VOTING MEMBER OF THE GOVERNING BOARD WHO RECEIVES COMPENSATION, DIRECTLY OR INDIRECTLY, FROM THE ORGANIZATION FOR SERVICES IS PRECLUDED FROM VOTING ON MATTERS PERTAINING TO THAT MEMBER'S COMPENSATION. 2. A VOTING MEMBER OF ANY COMMITTEE WHOSE JURISDICTION INCLUDES COMPENSATION MATTERS AND WHO RECEIVES COMPENSATION, DIRECTLY OR INDIRECTLY, FROM THE ORGANIZATION FOR SERVICES IS PRECLUDED FROM VOTING ON MATTERS PERTAINING TO THAT MEMBER'S COMPENSATION. 3. NO VOTING MEMBER OF THE GOVERNING BOARD OR ANY COMMITTEE WHOSE JURISDICTION INCLUDES COMPENSATION MATTERS AND WHO RECEIVES COMPENSATION, DIRECTLY OR INDIRECTLY, FROM THE ORGANIZATION, EITHER INDIVIDUALLY OR COLLECTIVELY, IS PROHIBITED FROM PROVIDING INFORMATION TO ANY COMMITTEE REGARDING COMPENSATION. ANNUAL STATEMENTS: EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: 1. HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, 2. HAS READ AND UNDERSTANDS THE POLICY, 3. HAS AGREED TO COMPLY WITH THE POLICY. PERIODIC REVIEWS: TO ENSURE THE ORGANIZATION OPERATES IN A MANNER CONSISTENT WITH PUBLIC HOSPITAL DISTRICT REQUIREMENTS, PERIODIC REVIEWS SHALL BE CONDUCTED. THE PERIODIC REVIEWS SHALL, AT A MINIMUM, INCLUDE THE FOLLOWING SUBJECTS: 1. WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE, BASED ON COMPETENT SURVEY INFORMATION AND THE RESULT OF ARM'S LENGTH BARGAINING. 2. WHETHER PARTNERSHIPS, JOINT VENTURES AND ARRANGEMENTS WITH MANAGEMENT ORGANIZATIONS CONFORM TO THE ORGANIZATION'S WRITTEN POLICIES, ARE PROPERLY RECORDED, REFLECT REASONABLE INVESTMENT OR PAYMENTS FOR GOODS AND SERVICES, FURTHER CHARITABLE PURPOSES AND DO NOT RESULT IN INUREMENT, IMPERMISSIBLE PRIVATE BENEFIT OR IN AN EXCESS BENEFIT TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15B THE COMPENSATION FOR KEY EMPLOYEES IS REVIEWED BY THE COMPENSATION COMMITTEE, ALL COMPENSATION IS REVIEWED AGAINST HHRAM AND MMGMA AVERAGES FOR REASONABLENESS. LONGVILLE LAKES CLINIC DOES NOT COMPENSATE ANY TOP MANAGEMENT OFFICIALS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST FOR THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN SECTION 6104(D). FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 360,816. MANAGEMENT AND GENERAL EXPENSES 50,856. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 411,672. CUYUNA REGIONAL MEDICAL CENTER 320 E MAIN STREET CROSBY MN 56441 410879376 HEALTH CARE MN 115 N/A 0 CUYUNA RANGE HEALTH CORP 320 EAST MAIN STREET CROSBY MN 56441 411696402 HEALTH CARE MN CUYUNA RANGE HOSPITAL DISTRICT C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0