2013-05-15T16:29:22-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 331007002 TRINITY HEALTH & AFFILIATES TRIN 7018575160 PO BOX 5020 MINOT ND 587025020 JOHN M KUTCH 7018575160 2013-05-15 1 KOREY BOELTER P00775161 6123764500 2011 2016-02-25 16:41:14Z JOHN M KUTCH PO BOX 5020 MINOT ND 587025020 300375688 1 0 3904 X WWW.TRINITYHEALTH.ORG X MEETING THE NEEDS OF THE WHOLE PERSON THROUGH QUALITY HEALTH CARE AND HEALTH RELATED SERVICES. 13 9 0 314 1491949 0 2237788 2311018 242014918 289982315 1356665 1021896 384049 6040222 245993420 299355451 417669 574174 0 0 112977769 119323020 0 0 579086 125096428 153472521 238491866 273369715 7501554 25985736 508339689 569541785 274590263 309204107 233749426 260337678 X TRINITY HEALTH IS COMMITTED TO PRESERVING AND IMPROVING THE QUALITY OF HEALTH OF THE PEOPLE WE SERVE. OUR MISSION IS TO EXCEL AT MEETING THE NEEDS OF THE WHOLE PERSON THROUGH THE PROVISION OF QUALITY HEALTH CARE AND HEALTH RELATED SERVICES. 0 0 145199097 574174 142286571 TRINITY HEALTH & AFFILIATES PROVIDES HOSPITAL SERVICES TO CENTRAL AND NORTHWEST NORTH DAKOTA AND NORTHEASTERN MONTANA. TRINITY HOSPITALS IS THE LARGEST HOSPITAL PROVIDER IN NORTHWEST NORTH DAKOTA, WITH AN ACUTE CARE FACILITY WHICH IS VERIFIED BY THE AMERICAN COLLEGE OF SURGEONS AS A LEVEL 2 TRAUMA CENTER. THE FACILITY ALSO INCLUDES A NEONATAL INTENSIVE CARE UNIT, A KIDNEY DIALYSIS UNIT, AN INPATIENT REHABILITATION CENTER, AND INPATIENT PSYCHIATRIC UNIT AND A COMPREHENSIVE COMPLIMENT OF BOTH ACUTE CARE AND OUTPATIENT SERVICES ALONG WITH A SKILLED NURSING HOME FACILITY AND A CRITICAL ACCESS HOSPITAL IN KENMARE. TRINITY PROVIDED COMMUNITY EDUCATION PROGRAMS AND EVENTS, SCREENINGS AND SUPPORT OF UND FAMILY MEDICINE. 24387501 0 74682853 TRINITY HOSPITALS PHARMACY DEPARTMENT PROVIDES COMPREHENSIVE PHARMACEUTICAL SERVICES 24 HOURS PER DAY TO PROVIDERS AND PATIENTS. THROUGH INVESTMENTS IN TECHNOLOGY, OUR MEDICATION MANAGEMENT PROCESS ENSURES THE SAFE AND EFFECTIVE ADMINISTRATION AND MONITORING OF ALL MEDICATIONS. IN ADDITION TO PROVIDING MEDICATIONS AND RELATED SUPPLIES, THE PHARMACY PROVIDES DRUG INFORMATION TO PATIENTS AND HEALTHCARE PROVIDERS, DOSING AND PHARMACOKENETIC SERVICES, ADVERSE DRUG REACTION MONITORING, DRUG-DRUG AND DRUG-FOOD INTERACTION OF INFORMATION, DRUG COMPATABILITIES, TOXICOLOGY AND ANTURAL PRODUCT INFORMATION. SERVICES RANGE FROM MEDICATION DISPENSING TO PERFORMING COMPLEX PHARMACOKINETIC CALCLUATIONS AND COMPOUNDING SPECIALIZED NUTRITION SOLUTIONS, CHEMOTHERAPY AND BIOLOGICAL REGIMENS. THE PHARMACY DEPARTMENT ALSO PARTICIPATED IN FMEA (FAILURE MODE EFFECT ANALYSIS) AND ROOT CAUSE ANALYSIS IN COOPERATION WITH OTHER DEPARTMENTS. RETROSPECTIVE AND CONCURRENT CHART REVIEWS ARE CONDUCTED TO ASSESS TIMELINESS AND APPROPRIATENESS OF THERAPY, AS WELL AS HOW WELL THE PATIENTS' NEEDS ARE BEING MET. 20229749 0 17825049 TRINITY HOMES IS A 292 BED HOSPITAL BASED SKILLED NURSING FACILITY PARTICIPATING IN MEDICARE AND MEDICAID PROGRAMS. RESIDENTS OF TRINITY HOMES, UNDER THE DIRECTION OF THEIR PHYSICIAN, ARE ABLE TO RECEIVE SKILLED NURSING CARE, PHYSICAL THERAPY, SPEECH THERAPY, OCCUPATIONAL THERAPY, DIETETIC SERVICES, SOCIAL SERVICE AND ACTIVITIES OF DAILY LIVING ASSISTANCE, SPIRITUAL CARE AND RECREATIONAL ACTIVITIES. 10617572 0 55187842 TRINITY HOSPITALS LABORATORY IS STAFFED 24/7, 365 DAYS A YEAR TO SERVE HOSPITAL, CLINIC AND OUTREACH PATIENTS. OUR PURPOSE IS TO PROVIDE LABORATORY TESTING TO AID THE PROVIDER IN DIAGNOSIS, TREATMENT, AND FOLLOW-UP OF DISEASE AND WELLNESS. WE PROVIDE ROUTINE TESTING FREE OF CHARGE TO THE COMMUNITY "FREE CLINIC"; HAVE DONE PSA SCREENINGS AT THE NORTH DAKOTA STATE FARE; AND DO SOME SCREENING TESTS FOR COMPANIES IN TOWN. WE HAVE PHLEBOTOMIST WHO GOES TO ASSISTED LIVING FACILITIES, NURSING HOMES, AND PRIVATE HOMES TO DRAW BLOOD. 10617572 55187842 200433919 1 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 2 0 0 1 1 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X MAX OWENS 7018575160 PO BOX 5020 MINOT ND 58702 X PATRICK HOLIEN 2.00 X X 0 0 0 TIMOTHY MIHALICK 2.00 X X 0 0 0 BLAINE DESLAURIERS 2.00 X X 0 0 0 KAREN KREBSBACH 2.00 X X 0 0 0 DAVID FULLER 2.00 X 0 0 0 CLARA SUE PRICE 2.00 X 0 0 0 MARTIN ROTHBERG MD 40.00 X 0 802667 34771 KEVIN COLLINS MD 40.00 X 0 969732 42143 BORGI BEELER 2.00 X 0 0 0 JOHN COUGHLIN 2.00 X 0 0 0 STEVEN LYSNE 2.00 X 0 0 0 DARYL SOMERVILLE 2.00 X 0 0 0 JOHN M KUTCH 40.00 X X 0 402846 33280 ALISON REPNOW 40.00 X 0 41349 5962 KEVIN SEEHAFER 40.00 X 0 213072 29773 RANDY SCHWAN 40.00 X 0 160940 23895 PAUL SIMONSON 40.00 X 0 222648 32922 THOMAS WARSOCKI 40.00 X 0 151996 25850 DAVE KOHLMAN 40.00 X 0 160640 26327 JOHN SHEENAN MD 40.00 X 0 141676 32869 JEFFREY VERHEY MD 40.00 X 0 520810 42143 0 3788376 329935 0 1 1 0 0 32581 25000 2253437 5345 2311018 NET PATIENT REVENUE 621110 286563827 286563827 DIETARY SERVICES 722320 1711107 371780 1339327 ADMINISTRATIVE SERVICE 561000 621200 621200 OTHER PATIENT SERVICES 621110 587212 587212 LABORATORY SERVICES 621500 356615 356615 142354 142354 289982315 449287 449287 49826 38801 11025 11025 11025 1542543 969934 572609 572609 572609 17133 32581 11502 5631 5631 FLOOD RECOVERY FUNDS 900099 5559023 5559023 VENDOR REBATES 900099 464543 464543 6023566 299355451 287151039 1491949 8401445 80570 80570 493604 493604 99219062 73462628 25673942 82492 4943539 3321374 1619095 3070 8251579 6457655 1778354 15570 6908840 5111180 1791752 5908 451806 13093 438713 159333 159333 31847384 16992990 14816897 37497 3890605 1272469 2613716 4420 9123804 3407166 5325694 390944 532399 367499 164900 8395177 4889982 3505195 190294 139426 50868 380876 172855 207361 660 4185713 89474 4054388 41851 11151174 3492655 7657988 531 846783 63454 783329 MEDICAL SUPPLIES / DRUG 45362726 45111351 251375 BAD DEBT EXPENSE 35113936 35117803 -3867 DUES & FEES 1583142 238005 1345127 10 BOOKS & SUBSCRIPTIONS 181675 99450 82225 75694 39236 36458 273369715 200433919 72356710 579086 19917936 6811547 1425844 4921844 35465 4420 398360380 77468571 550182 662488 6225426 7105650 2748412 2099290 219008431 147387770 62292807 71620661 12212523 12138104 4570714 386709210 508339689 569541785 41440652 50504887 144000 22455 29574 4200846 981285 58607 232145871 254266193 274590263 309204107 X 228808953 252711681 4845422 7515013 95051 110984 233749426 260337678 508339689 569541785 X 25985736 602516 X 0 1 1 X 0 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: THE PUBLIC CHARITY STATUS AS IDENTIFIED IN EACH OF THE CORPORATION'S DETERMINATION LETTER ARE AS FOLLOWS: TRINITY HOSPITALS - LINE 3, SECTION 170(B)(1)(A)(III) TRINITY KENMARE HOSPITAL - LINE 3, SECTION 170(B)(1)(A)(III) TRINITY HOMES - LINE 9, 509(A)(2) TRINITY HEALTH FOUNDATION - LINE 11, 509(A)(3) RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 46049 46049 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING ACTIVITIES CONSIST OF A PORTION OF OUR ANNUAL MEMBERSHIP DUES IDENTIFIED UPON RENEWAL AS ASSOCIATED WITH LOBBYING ACTIVITY. ASSOCIATIONS INCLUDE NORTH DAKOTA HEALTHCARE ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION, NORTH DAKOTA LONG TERM CARE ASSOCIATION, NATIONAL HOSPICE ASSOCATION, HEALTH POLICY CONSORTIUM, AND SECTION 508 HOSPITAL COALITION. 1 259075 13909 2135 270849 1 95051 7202 102253 95145 3902 3693 303 95051 305323 -214179 4001 95145 313288 -5031 2934 305232 0.00000 1.00000 0.00000 0 0 2155215 2155215 44142215 23432235 20709980 19447 19447 0 163594551 123936088 39658463 9097003 9097003 71620661 INVESTMENT IN UMCSC UNIT 50000 DUE FROM AFFILIATES 386659210 386709210 DUE TO AFFILIATES 248289418 ESTIMATED 3RD PARTY SETTLEMENTS 5976775 254266193 299355451 273369715 25985736 -571088 2402316 -1228712 602516 26588252 PART IV, LINE 1B: TO PROVIDE PUBLIC EDUCATION FOR HOSPICE CARE. PART IV, LINE 2B: RESIDENT TRUST FUNDS ARE RESIDENT FUNDS HELD BY TRINITY HOMES. THESE FUNDS ARE TRACKED SEPARATELY FROM THE ORGANIZATIONS AND ARE HELD IN A SEPARATE BANK ACCOUNT. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE PURPOSE OF THE ENDOWMENT FUNDS IS TO PROVIDE FUNDS FOR STAFF EDUCATION AND SCHOLARSHIPS AND FOR THE PURCHASE OF NEW EQUIPMENT. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: TRINITY HEALTH AND THE FOLLOWING SUBSIDIARIES, TRINITY HOSPITALS, TRINITY HOMES, TRINITY HEALTH FOUNDATION, TRINITY KENMARE HOSPITAL AND COMMUNITY ABMULANCE SERVICE HAVE ALL BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC) AND IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE IRC. ALL UNRELATED BUSINESS INCOME GENERATED BY TRINITY IS SUBJECT TO FEDERAL INCOME TAX UNDER 511 OF THE IRC. TRINITY'S POLICY IS TO EVALUATE THE LIKELIHOOD THAT ITS UNCERTAIN TAX POSITIONS WILL PREVAIL UPON EXAMINATION BASED ON THE EXTENT TO WHICH THOSE POSITIONS HAVE SUBSTANTIAL SUPPORT WITHIN THE INTERNAL REVENUE CODE AND REGULATIONS, REVENUE RULINGS, COURT DECISIONS, AND OTHER EVIDENCE. IT IS THE OPINION OF MANAGEMENT THAT THE COMPANY HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS THAT WOULD BE SUBJECT TO CHANGE UPON EXAMINATION. TRINITY'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE TAX RETURNS FOR THE YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS -1,228,712. GOLF 49714 32581 17133 4306 5500 1696 49714 32581 17133 4306 5500 1696 11502 5631 1 1 X 1 X 1 X 1 1 1 0 1 0 2137527 2137527 0.00900 17530061 17193830 336231 0.00140 19667588 17193830 2473758 0.01040 19667588 17193830 2473758 0.01040 26 4640 93751 93751 0.00040 26 4640 93751 93751 0.00040 1 35117803 0 70816039 58997794 11818245 X 1 1 3 1 TRINITY HOSPITAL

ONE BURDICK EXPRESSWAY WEST MINOT ND 58701

X X X X 2 TRINITY HOSPITAL ST JOSEPH'S

407 3RD STREET SE MINOT ND 58701

X X 3 TRINITY KENMARE HOSPITAL

PO BOX 697 KENMARE ND 587460697

X X X TRINITY HOSPITAL 1 1 1 150.000000000000 1 250.000000000000 1 X X X X 1 1 X X X X X 1 0 1 X 0 0 TRINITY HOSPITAL ST JOSEPH'S 2 1 1 150.000000000000 1 250.000000000000 1 X X X X 1 1 X X X X X 1 0 1 X 0 0 TRINITY KENMARE HOSPITAL 3 1 1 150.000000000000 1 250.000000000000 1 X X X X 1 1 X X X X X 1 0 1 X 0 0 13 TRINITY HOMES

305 8TH AVENUE NE MINOT ND 58701

SKILLED NURSING HOME TRINITY HEALTH CENTER MEDICAL ARTS

400 BURDICK EXPRESSWAY EAST MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY HEALTH CENTER-EAST

20 BURDICK EXPRESSWAY WEST MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY HEALTH CENTER-WEST

101 ERD AVENUE SW MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY REGIONAL EYECARE-MINOT CENTER

120 BURDICK EXPRESSWAY EAST MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY HEALTH CENTER-RIVERSIDE

1900 8TH AVENUE SE MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY HEALTH CENTER-TOWN & COUNTRY

831 SOUTH BROADWAY MINOT ND 58701

PROVIDER-BASED CLINIC MAIN MEDICAL BUILDING

315 SOUTH MAIN MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY HEALTH SOUTH RIDGE

1500 24TH AVENUE SW MINOT ND 58701

PROVIDER-BASED CLINIC PLAZA 16

2815 16TH STREET SW MINOT ND 58701

PROVIDER-BASED CLINIC TRINITY COMMUNITY CLINIC KENMARE

307 1ST AVENUE NW KENMARE ND 58746

RURAL HEALTH CLINIC TRINITY HOSPITALS HOME HEALTHHOSPICE

1015 SOUTH BROADWAY SUITE 306 MINOT ND 58701

HOME HEALTH & HOSPICE TRINITY HOSPITALS

HOSPITAL ROAD BELCOURT ND 58316

DIALYSIS SERVICES PART I, LINE 7: TRINITY'S COMMUNITY BENEFIT EXPENSES AND REVENUES WERE CALCULATED USING THE IRS WORKSHEETS PROVIDED IN THE INSTRUCTIONS TO THE 2011 FORM 990, SCHEDULE H. PART I, L7 COL(F): IN FURTHERANCE OF ITS CHARITABLE PURPOSE, TRINITY PROVIDES A WIDE VARIETY OF BENEFITS TO THE COMMUNITY, INCLUDING OFFERING VARIOUS COMMUNITY-BASED SERVICE PROGRAMS SUCH AS FREE CLINICS, HEALTH SCREENINGS, IN-HOME CAREGIVER SERVICES, SOCIAL SERVICE AND SUPPORT COUNSELING FOR PATIENTS AND FAMILIES, PASTORAL CARE, CRISIS INTERVENTION, TRANSPORTATION TO AND FROM THE HOSPITAL CAMPUSES, AND THE DONATION OF SPACE FOR USE BY COMMUNITY GROUPS. ADDITIONALLY, A LARGE NUMBER OF HEALTH-RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, TELEPHONE INFORMATION SERVICES, AND COSTS RELATED TO PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. THE COST OF PROVIDING THE ABOVE SERVICES IS NOT INCLUDED IN TRINITY'S CHARITY CARE AMOUNT.TRINITY ALSO PROVIDES MEDICAL CARE WITHOUT CHARGE OR AT REDUCED CHARGE TO RESIDENTS OF ITS COMMUNITY THROUGH THE PROVISION OF CHARITY CARE. INCLUDED IN TRINITY'S DEFINITION O CHARITY CARE ARE THE FOLLOWING: (A) SERVICES PROVIDED TO THE UNINSURED OR UNDERINSURED AND (B) SERVICES PROVIDED TO PATIENTS EXPRESSING A WILLINGNESS TO PAY BUT WHO ARE DETERMINED TO BE UNABLE TO PAY BECAUSE OF SOCIOECONOMIC FACTORS. TRINITY MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THOSE RECORDS INCLUDE THE AMONT OF CHARGES FOREGONE FOR CHARITY CARE.AMOUNTS DO NOT INCLUDE THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS OR THE DIFFERENCE BETWEEN PUBLIC PROGRAM PAYMENTS (PRIMARILY MEDICARE AND MEDICAID) AND THE RELATED COSTS OF PROVIDING SUCH SERVICES. TRINITY USES THE MEDICARE COST-TO-CHARGE RATIO TO DETERMINE THE AMOUNTS REPORTED ON LINES 2 AND 3. PART III, LINE 4: FROM THE NOTE 1, "PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, NET":"PATIENT RECEIVABLES DUE DIRECTLY FROM PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. AT JUNE 30, 2012, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WAS APPROXIMATELY $70,882,000."PATIENT RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A RECOVERY OF BAD DEBT WHEN RECEIVED." PART III, LINE 9B: IT IS THE POLICY OF TRINITY TO PROVIDE MEDICAL SERVICES TO THE COMMUNITY AND REGION REGARDLESS OF THE CUSTOMER'S ABILITY TO PAY THROUGH CONSISTENT BILLING PRACTICES. ACCOUNTS WILL BE MONITORED TO ENSURE THAT CUSTOMERS ARE BILLED FOR ONLY THOSE SERVICES PROVIDED. TRINITY, THROUGH VERIFICATION OF INFORMATION, IS REQUIRED TO PROVIDE TIMELY AND ACCURATE BILLING, COLLECTION, AND PATIENT ACCOUNT MAINTENANCE. INFORMATION REGARDING TRINITY'S BILLING AND PAYMENT GUIDELINES, WHICH INCLUDES FINANCIAL ASSISTANCE PROGRAMS, ARE AVAILABLE AT REGISTRATION AND BUSINESS SERVICES LOCATIONS. THIS INFORMATION IS COMMUNICATED VERBALLY OR THROUGH THE USE OF THE TRINITY BILLING & PAYMENT GUIDELINES BROCHURE. TO ENHANCE VERBAL COMMUNICATIONS, INTERPRETERS ARE PROVIDED AS NECESSARY. TRINITY HOSPITAL PART V, SECTION B, LINE 13G: PATIENTS IDENTIFIED AS POSSIBLE FINANCIAL ASSISTANCE CASES ARE ASKED TO BE COPMLETE A FINANCIAL ASSISTANCE FORM AND ARE REFERRED TO THE APPROPRIATE COUNSELOR. TRINITY HOSPITAL ST. JOSEPH'S PART V, SECTION B, LINE 13G: PATIENTS IDENTIFIED AS POSSIBLE FINANCIAL ASSISTANCE CASES ARE ASKED TO BE COPMLETE A FINANCIAL ASSISTANCE FORM AND ARE REFERRED TO THE APPROPRIATE COUNSELOR. TRINITY KENMARE HOSPITAL PART V, SECTION B, LINE 13G: PATIENTS IDENTIFIED AS POSSIBLE FINANCIAL ASSISTANCE CASES ARE ASKED TO BE COPMLETE A FINANCIAL ASSISTANCE FORM AND ARE REFERRED TO THE APPROPRIATE COUNSELOR. TRINITY HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ALL COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNT THAT CAN BE CHARGED. TRINITY HOSPITAL ST. JOSEPH'S PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ALL COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNT THAT CAN BE CHARGED. TRINITY KENMARE HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ALL COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNT THAT CAN BE CHARGED. PART VI, LINE 2: TRINITY HEALTH COMPLETES A THOROUGH COMMUNITY HEALTH NEEDS ASSESSMENT EVERY THREE YEARS, IN COMPLIANCE WITH SECTION 501(R). TRINITY'S FIRST COMMUNITY HEALTH NEEDS ASSESSMENT WILL BE COMPLETED BY JUNE 30, 2013. PART VI, LINE 3: TRINITY POSTS NOTICE OF ITS FINANCIAL ASSISTANCE PROGRAM AND HOW A PATIENT MAY APPLY. PATIENT ACCESS AND BUSINESS OFFICE STAFF ATTEMPT TO IDENTIFY ALL CASES THAT WILL QUALIFY FOR FINANCIAL ASSISTANCE AT THE TIME OF ADMISSION. PATIENTS IDENTIFIED AS POSSIBLE FINANCIAL ASSISTANCE CASES ARE ASKED TO COMPLETE A FINANCIAL ASSISTANCE FORM AND ARE REFERRED TO THE APPROPRIATE COUNSELOR. PART VI, LINE 5: IN FURTHERANCE OF ITS CHARITABLE PURPOSE, TRINITY PROVIDES A WIDE VARIETY OF BENEFITS TO THE COMMUNITY, INCLUDING OFFERING VARIOUS COMMUNITY-BASED SERVICE PROGRAMS SUCH AS FREE CLINICS, HEALTH SCREENINGS, IN-HOME CAREGIVER SERVICES, SOCIAL SERVICE AND SUPPORT COUNSELING FOR PATIENTS AND FAMILIES, PASTORAL CARE, CRISIS INTERVENTION, TRANSPORTATION TO AND FROM THE HOSPITAL CAMPUSES, AND THE DONATION OF SPACE FOR USE BY COMMUNITY GROUPS. ADDITIONALLY, A LARGE NUMBER OF HEALTH-RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, TELEPHONE INFORMATION SERVICES, AND COSTS RELATED TO PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. 0 MINOT FAMILY YMCA PO BOX 69 MINOT ND 58702 450237612 501(C)(3) 50000 FACILITY EXPANSION NORSK HOSTFEST ASSOCIATION PO BOX 1347 MINOT ND 58702 450353644 501(C)(3) 23400 SPONSORSHIP NORTH DAKOTA STATE FAIR PO BOX 1796 MINOT ND 58702 450215346 501(C)(3) 7170 SPONSORSHIP 3 0 INDIVIDUAL GRANTS WERE GIVEN FOR HARDSHIPS AND FLOOD RELIEF. 715 493604 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: TRINITY HEALTH & AFFILIATES DOES NOT HAVE A PROCEDURE FOR MONITORING USE OF GRANT FUNDS. X 0 0 0 0 0 0 0 0 0 0 0 MARTIN ROTHBERG MD 0 775584 0 27083 0 0 0 23704 0 11067 0 837438 0 0 KEVIN COLLINS MD 0 441451 0 510611 0 17670 0 23704 0 18439 0 1011875 0 0 JOHN M KUTCH 0 402846 0 0 0 0 0 23704 0 9576 0 436126 0 0 KEVIN SEEHAFER 0 213072 0 0 0 0 0 22204 0 7569 0 242845 0 0 RANDY SCHWAN 0 160940 0 0 0 0 0 17098 0 6797 0 184835 0 0 PAUL SIMONSON 0 220848 0 0 0 1800 0 23686 0 9236 0 255570 0 0 THOMAS WARSOCKI 0 151996 0 0 0 0 0 16789 0 9061 0 177846 0 0 DAVE KOHLMAN 0 159289 0 0 0 1351 0 17243 0 9084 0 186967 0 0 JOHN SHEENAN MD 0 137309 0 0 0 4367 0 14973 0 17896 0 174545 0 0 JEFFREY VERHEY MD 0 290443 0 130000 0 100367 0 23704 0 18439 0 562953 0 0 PART I, LINE 1A TRINITY HEALTH OWNS THEIR OWN AIRPLANE AND DURING FY 2012 OFFICERS USED THIS PLANE FOR BUSINESS USE TRAVEL. BECAUSE THE USE WAS RESTRICTED FOR BUSINESS THIS DID NOT EFFECT THE OFFICER'S COMPENSATION. SUPPLEMENTAL INFORMATION PART III JOHN KUTCH, PRESIDENT/CEO, IS COMPENSATED BY TRINITY HEALTH, A RELATED ORGANIZATION. TRINITY HEALTH USES THE FOLLOWING METHODS TO DETERMINE THE COMPENSATION FOR JOHN: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSISTE OF THE BOARD OF DIRECTORS CHAIRMAN, VICE CHAIRMAN, SECRETARY, TREASURER, AND ONE ADDITIONAL MEMBER OF THE BOARD OF DIRECTORS ELECTED BY THE BOARD OF DIRECTORS AT ITS FIRST MEETING AFTER ITS ELECTION. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF CORPORATION DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF DIRECTORS AND WITH THE UNDERSTANDING THAT ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 TRINITY HEALTH SHALL BE THE SOLE MEMBER OF EACH CORPORATION INCLUDED IN THIS GROUP RETURN. FORM 990, PART VI, SECTION A, LINE 7A AT EACH ANNUAL MEETING, THE SOLE MEMBER TRINITY HEALTH, SHALL APPOINT THE BOARD OF DIRECTORS. AT LEAST SEVEN OF THE BOARD OF DIRECTORS SHALL ALSO SERVE AS A MEMBER OF THE BOARD OF DIRECTORS OF TRINITY HEALTH. IN THE BYLAWS OF TRINITY HEALTH FOUNDATION, THIS OVERLAP ONLY NEEDS TO BE THREE. ANY DIRECTOR WHO IS, AT THE TIME OF ELECTION, A MEMBER OF THE BOARD OF DIRECTORS OF TRINITY HEALTH SUBSEQUENTLY CEASES TO BE A MEMBER OF SUCH BOARD SHALL AUTOMATICALLY BECOME DISQUALIFIED FROM SERVING AS A DIRECTOR OF THE AFFILIATES' BOARD AND REPLACED WITH ANOTHER BOARD MEMBER CURRENTLY SERVING ON THE BOARD OF TRINITY HEALTH, UNLESS THERE ARE AT LEAST A MINIMUM OF SEVEN (OR THREE IN THE CASE OF TRINITY HEALTH FOUNDATION) OTHER BOARD MEMBERS CURRENTLY SERVING AS A DIRECTOR OF TRINITY HEALTH. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING POWERS SHALL BE RESERVED EXCLUSIVELY TO THE SOLE MEMBER, TRINITY HEALTH: (A) THE RIGHT TO APPROVE THE APPOINTMENT OF OFFICERS OF CORPORATION; (B) THE RIGHT TO APPROVE ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OF CORPORATION OR THESE BYLAWS; (C) THE RIGHT TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF CORPORATION; (D) THE RIGHT TO APPROVE THE SELECTION OF AUDITORS AND LEGAL COUNSEL FOR CORPORATION; (E) THE RIGHT TO APPROVE ANY STRATEGIC PLANS ADOPTED BY CORPORATION; (F) THE RIGHT TO APPROVE ANY UNBUDGETED BORROWING, ANY ENCUMBRANCE OF ASSETS, AND ANY EXPENDITURES FOR CAPITAL IMPROVEMENTS WHERE THE AMOUNT EXCEEDS FIVE PERCENT OF THE CAPITAL BUDGET PREVIOUSLY APPROVED BY MEMBER; (G) THE RIGHT TO CHANGE THE NUMBER OF DIRECTORS OF THE BOARD OF DIRECTORS OF CORPORATION; AND (H) THE RIGHT TO APPROVE ANY ACTION OF CORPORATION THAT IS NOT IN THE ORDINARY COURSE OF THE CORPORATION'S BUSINESS. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO BEING FILED WITH THE IRS, A COPY OF THE FORM 990 IS EMAILED TO THE GOVERNING BODY OF TRINITY HEALTH & AFFILIATES FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL SALARIED EMPLOYEES (AT MANAGER LEVEL AND ABOVE AS DETERMINED BY TRINITY) AND SUCH OTHER EMPLOYEES AS FROM TIME TO TIME MAY BE DIRECTED TO DO SO, ARE REQUIRED TO COMPLETE TRINITY HEALTH'S CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS. ANY EMPLOYEE WHO HAS ASSUMED, OR IS ABOUT TO ASSUME, A FINANCIAL OR OTHER INTEREST OR RELATIONSHIP THAT MIGHT INVOLVE A CONFLICT OF INTEREST MUST IMMEDIATELY INFORM HIS/HER SUPERVISOR, A MEMBER OF THE COMPLIANCE COMMITTEE, OR THE COMPLIANCE OFFICER. ISSUES INVOLVING CONFLICT OF INTEREST SHALL BE REVIEWED AND A DETERMINATION OF EACH SHALL BE MADE BY THE TRINITY COMPLIANCE COMMITTEE. IF A CONFLICT EXISTS, THE CONFLICTED PERSON MUST ABSTAIN FROM DISCUSSION OF AND VOTING ON THE CONFLICTED TOPIC. FORM 990, PART VI, SECTION C, LINE 19 ON OUR WEBSITE WWW.TRINITYHEALTH.ORG WE LIST OUR BOARD OF DIRECTORS, MISSION, VISION, VALUES AND OUR ANNUAL REPORT WHICH INCLUDES FINANCIAL INFORMATION. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE UPON REQUEST. BOARD OVERLAP FORM 990, PART VII, SECTION A ALL OF THE BOARD MEMBERS OF TRINITY HEALTH & AFFILIATES, ALSO SERVE ON THE BOARD OF DIRECTORS FOR TRINITY HEALTH, A RELATED ORGANIZATION. EACH BOARD MEMBER SERVES AN AVERAGE OF 2 HOURS PER WEEK SERVING ALL ORGANIZATIONS. JOHN KUTCH, PRESIDENT/CEO OF TRINITY HEALTH & AFFILIATES, ALSO SERVES AS THE PRESIDENT/CEO FOR TRINITY HEALTH, A RELATED ORGANIZATION. ON AVERAGE, JOHN KUTCH WORKS 40 HOURS PER WEEK SERVING ALL ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -571,088. PRIOR PERIOD ADJUSTMENTS: 2,402,316. NET ASSETS RELEASED FROM RESTRICTIONS -1,228,712. TOTAL TO FORM 990, PART XI, LINE 5: 602,516. COMMUNITY AMBULANCE SERVICE OF MINOT INC 305 11TH AVENUE SW MINOT ND 58701 450363593 AMBULANCE SERVICES ND 501(C)(3) LINE 11A, I TRINITY HEALTH 0 MEDICAL ARTS OUTPATIENT SERVICES INC 400 BURDICK EXPRESSWAY EAST MINOT ND 58701 450278212 RETAIL PHARMACY & DURABLE MEDICAL EQUIPMENT ND TRINITY HOSPITALS C 11679074 6152277 1.00000 B&B DRUG INC 20 BURDICK EXPRESSWAY EAST MINOT ND 58701 450260565 RETAIL DRUG STORE ND N/A C 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 1 0 MEDICAL ARTS OUTPATIENT SERVICES INC A 72000 FMV TRINITY HOSPITALS PO BOX 5020 MINOT ND 58702 412002771 TRIN TRINITY KENMARE HOSPITAL PO BOX 697 KENMARE ND 58746 412002769 TRIN TRINITY HOMES PO BOX 5020 MINOT ND 58702 450404412 TRIN TRINITY HEALTH FOUNDATION PO BOX 5020 MINOT ND 58702 450215346 TRIN