2013-11-14T14:58:46-06:00 2012-12-31 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2012-01-01 411842965 LAKEWOOD HEALTH SYSTEM LAKE 2188941515 49725 COUNTY 83 STAPLES MN 56479 JIM DREGNEY 2188941515 2013-11-14 1 TIM A RITTER CPA P00732856 9525483400 2013-11-14 2012 2016-02-25 16:41:14Z JIM DREGNEY 49725 COUNTY 83 STAPLES MN 56479 92691356 0 X WWW.LAKEWOODHEALTHSYSTEM.COM X 1996 MN TO PROVIDE PERSONALIZED HEALTHCARE FOR A LIFETIME. 12 7 1070 112 60013 -54338 230334 291186 84369027 91137423 251282 19310 795934 782839 85646577 92230758 0 0 0 0 45151743 47975460 0 0 308022 37597758 40673909 82749501 88649369 2897076 3581389 82524477 85105756 54000105 53013599 28524372 32092157 TO PROVIDE PERSONALIZED HEALTHCARE FOR A LIFETIME. 0 0 69748477 91183966 LAKEWOOD HEALTH SYSTEM PROVIDED FOR 4,296 INPATIENT HOSPITAL AND SWING-BED DAYS, 2,667 INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT DAYS, 34,971 RESIDENT DAYS IN THE NURSING HOME, 658 ASSISTED LIVING UNIT RENTED MONTHS, 61,796 MEDICAL AND MENTAL HEALTH RURAL HEALTH CLINIC VISITS AND PROVIDED AMBULANCE, HOSPICE/HOME CARE, AND OTHER PATIENT SERVICES. 69748477 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 83 0 1 1070 1 1 1 0 0 0 0 1 1 0 0 0 0 X 12 7 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 MN X JIM DREGNEY CFO 2188941515 49725 COUNTY 83 STAPLES MN 56479 CHRISTINE ALBRECHT MD 1.00 X 0 0 0 JULIE BENSON MD 1.00 X 0 0 0 BARB PETERSON 1.00 X 0 0 0 CAROLYN BISEL 1.00 X 0 0 0 WILLIAM MENNIS MD 1.00 X 0 0 0 MARIE ROSE 1.00 X 0 0 0 PAUL WICK 1.00 X 0 0 0 LOREN MOREY 1.00 X X 0 0 0 JIM HOFER 1.00 X X 0 0 0 SARAH ISRAELSON MD 1.00 X X 0 0 0 LARRY LUNDBLAD 1.00 X X 0 0 0 TIM RICE 40.00 X X 360623 0 36329 JAMES DREGNEY 40.00 X 179906 0 30952 CRAIG WOLHOWE 40.00 X 187620 0 32843 DANIEL DONAHUE 40.00 X 188477 0 32391 LAURIE BACH 40.00 X 192554 0 20958 LYNN NEWTON RICE 40.00 X 187819 0 13480 JEFFREY D OSEGARD 40.00 X 176812 0 32060 ROBERT SCHMIEG 40.00 X 339238 0 23877 SHERREE ENGEN 40.00 X 257098 0 32380 BRIAN L HINMAN 40.00 X 153734 0 19391 REBECCA LYNN BENNETT 40.00 X 150935 0 29655 AMY LYNN WINKELS 40.00 X 146199 0 29625 2521015 0 333941 43 0 1 0 LAKEWOOD CLINIC PA 49725 COUNTY 83 STAPLES MN 56479 PHYSICIAN SERVICES 9831367 MCKESSON TECHNOLOGIES PO BOX 98347 CHICAGO IL 60673 EMR 1678480 BWBR ARCHITECTS 380 ST PETER STREET ST PAUL MN 55102 ARCHITECTED SERVICES 896373 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM COVERAGE 648283 QUEST DIAGNOSTICS 12989 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB TEST SERVICES 485617 18 35417 64101 191668 291186 NET PATIENT AND RESIDENT SERVICE 621110 89400379 89340366 60013 OTHER SERVICE REVENUE 621110 810707 810707 OCCUPATIONAL HEALTH 621300 400276 400276 RENTAL REVENUE 531120 261911 261911 FASD 624100 84609 84609 179541 179541 91137423 187894 187894 14382 0 14382 14382 14382 283884 452468 -168584 -168584 -168584 12142 35417 8130 4012 4012 FOOD SERVICE 900099 756012 106556 649456 8433 8433 764445 92230758 91183966 60013 695593 1672824 1672824 34388266 26993686 7351799 42781 1395856 1095702 298417 1737 8003696 6282645 1711094 9957 2514818 1974051 537638 3129 29112 29112 28036 28036 7719066 6049093 1650244 19729 251897 197152 53853 892 10637994 7774112 2826205 37677 2518890 1971461 538508 8921 651617 510001 139308 2308 33403 26144 7141 118 1909954 1494864 408325 6765 4675040 3659015 999467 16558 256076 200423 54746 907 MEDICAL FEES 7939560 7939560 PROVISION FOR BAD DEBTS 1680643 1680643 MN CARE TAX 947238 744730 202508 SURCHARGES 834527 834527 560856 320668 83645 156543 88649369 69748477 18592870 308022 4918 4441 9743427 4341064 15623480 20410976 370887 1529945 1380588 1302882 1722974 1674745 85884991 34133619 49255497 51751372 660703 680129 3762003 3410202 82524477 85105756 9204769 8631584 40276116 38934881 4483904 5414061 35316 33073 54000105 53013599 X 28183502 31940899 340870 151258 28524372 32092157 82524477 85105756 X 3581389 -13604 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 523 523 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF MINNESOTA HOSPITAL ASSOCIATION AND A PORTION OF THE MEMBERSHIP DUES IS FOR LOBBYING EXPENSES. 340870 196691 386303 151258 190279 207943 2559 59911 340870 220292 196691 151258 265725 123893 93133 4328 1062 220292 270098 10996 6423 163624 123893 0.00000 0.00000 1.00000 0 0 838858 838858 33811444 13863812 19947632 160508 2675 157833 47739982 20267132 27472850 3334199 3334199 51751372 RESIDENTS PERSONAL ACCOUNT 6676 SENIOR HOUSING DEPOSITS 26397 33073 X 90550115 0 90550115 1680643 1680643 92230758 86968726 0 86968726 1680643 1680643 88649369 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: UNRESTRICTED NET ASSETS CONSIST OF INVESTMENTS AND OTHERWISE UNRESTRICTED AMOUNTS THAT ARE AVAILABLE FOR USE IN CARRYING OUT THE MISSION OF THE ORGANIZATION AND INCLUDE THOSE EXPENDABLE RESOURCES THAT HAVE BEEN DESIGNATED FOR SPECIAL USE BY THE ORGANIZATION'S BOARD OF DIRECTORS. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE ORGANIZATION HAS BEEN LIMITED BY DONORS TO A SPECIFIC TIME PERIOD OR PURPOSE. PERMANENTLY RESTRICTED NET ASSETS HAVE BEEN RESTRICTED BY DONORS TO BE MAINTAINED BY THE ORGANIZATION IN PERPETUITY. THE ORGANIZATION HAS NO PERMANENTLY RESTRICTED NET ASSETS DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 AND 2011. FEDERAL RETURNS FOR 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,680,643. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,680,643. DINNER AUCTION 31080 25055 6025 1961 2031 GOLF TOURNAMENT 16479 10362 6117 635 3074 429 47559 35417 12142 635 5035 2460 8130 4012 1 1 1 X 75.000000000000 1 X 240.000000000000 0 1 1 0 0 722706 722706 0.00830 22785159 21814608 970551 0.01120 23507865 21814608 1693257 0.01950 169789 6300 163489 0.00190 46261 0 46261 0.00050 3339102 1915344 1423758 0.01640 42261 42261 0.00050 3597413 1921644 1675769 0.01930 27105278 23736252 3369026 0.03880 11324 11324 0.00010 3221 3221 0.00000 14545 14545 0.00010 0 1680643 1042799 14931159 15594770 -663611 X 1 1 1 1 LAKEWOOD HEALTH SYSTEM

49725 COUNTY ROAD 83 STAPLES MN 56479

X X X X LAKEWOOD HEALTH SYSTEM 1 0 1 1 75.000000000000 1 240.000000000000 1 X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 7 STAPLES CLINIC

49725 COUNTY ROAD 83 STAPLES MN 56479

CLINIC PILLAGER CLINIC

653 PILLSBURY ST N STE 1 PILLAGER MN 56473

CLINIC MOTLEY CLINIC

1233 HWY 10 MOTLEY MN 56466

CLINIC BROWERVILLE CLINIC

30535 241ST AVE BROWERVILLE MN 56438

CLINIC EAGLE VALLEY CLINIC

815 HWY 71 S EAGLE BEND MN 56446

CLINIC LHS CARE CENTER

401 PRAIRIE AVE NE STAPLES MN 56479

SKILLED NURSING FACILITY ST CLOUD DERMATOLOGY CLINIC

2251 CONNETICUT AVE SO SUITE 3800 SARTELL MN 56377

CLINIC PART I, LINE 7G: AMOUNTS USED FOR SUBSIDIZED SERVICES WERE CALCULATED USING DETAILED REPORT DATA KEPT BY THE ORGANIZATION. DATA INCLUDED THE TOTAL CHARGES, ALLOWANCES AND DISCOUNTS, MEDICAID, AND ACTUAL COST OF SERVICES PROVIDED. SUBSIDIZED SERVICES ARE DETERMINED BY THE ORGANIZATION DUE TO THE NEED IN THE COMMUNITY THAT CAN ONLY BE FILLED BY THE ORGANIZATION. 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 $ 1680643. PART II: LAKEWOOD HEALTH SYSTEM HAS SET ASIDE A SMALL AREA OF LAND ON WHICH A COMMUNITY PARK WAS ESTABLISHED. TO PROMOTE PHYSICAL ACTIVITY IN CHILDREN, LHS PURCHASED PLAYGROUND EQUIPMENT FOR THE PARK. THIS PARK IS THE ONE MOST OFTEN UTILIZED BY CHILDREN AND IS AFFECTIONATELY KNOWN AS THE "DINO PARK" DUE TO SOME OF THE EQUIPMENT HAVING A DINOSAUR THEME.IN 2010, LAKEWOOD HEALTH SYSTEM CREATED A COMMUNITY RELATIONS DIRECTOR POSITION. THE RESPONSIBILITY OF THIS INDIVIDUAL IS TO WORK WITH VARIOUS COMMUNITY AGENCIES AND INDIVIDUALS TO HELP PROMOTE ECONOMIC GROWTH IN THE COMMUNITIES WHERE A LAKEWOOD HEALTH SYSTEM FACILITY IS LOCATED. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLY UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE.FINANCIAL STATEMENT FOOTNOTE 3 ACCOUNTS RECEIVABLE: THE ORGANIZATION'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS INCREASED FROM 46.1% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2011, TO 50.8% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2012. THE ORGANIZATION HAD $1,911,942 AND $6,311,915 OF SELF-PAY ACCOUNTS AT COLLECTION AGENCIES FOR THE YEARS ENDED DECEMBER 31, 2012 AND 2011, RESPECTIVELY. THE SELF-PAY ACCOUNTS HELD AT COLLECTION AGENCIES HAVE BEEN FULLY RESERVED FOR AND ARE INCLUDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AT THE NET OF THE RECEIVABLE AND ALLOWANCE. BAD DEBT WRITE-OFFS WERE APPROXIMATELY $4,079,000 AND $1,162,000 FOR THE YEARS ENDED DECEMBER 31, 2012 AND 2011, RESPECTIVELY. THE ORGANIZATION HAD NOT CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES THAT AFFECTED BAD DEBT WRITE-OFFS DURING 2012 OR 2011, BUT SUBSEQUENT TO DECEMBER 31, 2012, ADDENDUMS TO THE CHARITY CARE POLICY WERE APPROVED WHICH ARE EXPECTED TO INCREASE CHARITY CARE AMOUNTS THAT ARE AVAILABLE TO THE LOWEST INCOME PATIENTS AND REDUCE CHARITY CARE AMOUNTS THAT ARE AVAILABLE TO THOSE PATIENTS WITH A GREATER ABILITY TO PAY. PART III, LINE 8: THE MEDICARE ALLOWABLE COST OF CARE RELATING TO PAYMENTS ON LINE 5 WERE CALCULATED USING OUR FILED 2012 MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS ARE REQUIRED TO APPLY FOR MEDICAL ASSISTANCE IN ORDER TO RECEIVE A 50% OR GREATER DISCOUNT PER LAKEWOOD'S CUSTOMER ASSITANCE PROGRAM. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 11: INCOME OF 75% TO 240% OF FPG WOULD BE ELIGIBLE FOR DISCOUNTED CARE. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 12H: THE AMOUNT INVOICED DOES NOT CHANGE, HOWEVER A DISCOUNT AMOUNT IS DETERMINED BY INCOME LEVEL AND UNINSURED STATUS THAT WILL RESULT IN THE AMOUNT OF PAYMENT, IF ANY, FROM THE FAP-ELIGIBLE PATIENT. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 14G: EACH APPLICABLE ADMISSION AREA HAS A POLICY AVAILABLE FOR THE PATIENT AS NEEDED AND UPON REQUEST. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 20D: UNINSURED PATIENTS MEETING INCOME GUIDELINES WILL NOT BE CHARGED MORE IN WHICH THE PROVIDER WOULD BE REIMBURSED FROM OUR MOST FAVORED INSURER. CHARITY CARE DISCOUNTS ARE DETERMINED BASED ON INCOME LEVELS USING THE FPG. PART VI, LINE 2: THE ORGANIZATION CONDUCTS COMMUNITY SURVEYS AND USES PATIENT FEEDBACK TO ASSESS THE NEEDS OF THE COMMUNITIES IT SERVES. PART VI, LINE 3: PATIENT FINANCIAL SERVICES (PFS) STAFF ARE AVAILABLE AND UTILIZED THROUGHOUT THE PATIENT EXPERIENCE. PFS STAFF EDUCATE PATIENTS ON MEANS-TESTED PROGRAMS AVAILABLE TO THE PATIENT AS WELL AS ASSIST THE PATIENT WITH THE CUSTOMER ASSISTANCE APPLICATION PROCESS. PAYMENT PLANS ARE ALSO ESTABLISHED TO ASSIST PATIENTS IN PAYING OFF OBLIGATIONS OWED TO THE ORGANIZATION. PART VI, LINE 4: LAKEWOOD HEALTH SYSTEM OFFERS A BROAD SPECTRUM OF CARE. OUR SYSTEM INCLUDES A NEW, STATE-OF-THE-ART MAIN CAMPUS WITH A 25-BED, CRITICAL ACCESS HOSPITAL AND CLINIC (STAPLES, MN); FOUR MODERN SATELLITE CLINICS BROWERVILLE, PILLAGER, MOTLEY & EAGLE BEND, MN), SENIOR SERVICES, HOUSING AND A SPECIALIZED SENIOR BEHAVIORAL HEALTH UNIT (STAPLES, MN), AND A MEDICAL SPA (BAXTER, MN). WE ALSO HAVE ON-STAFF SPECIALISTS AND VISITING PARTNERS, WHICH ALLOWS US TO OFFER COMPREHENSIVE CARE IN THESE VARIOUS COMMUNITIES. ITS NEIGHBOR, MOTLEY, IS JUST A FEW MILES AWAY AND HAS ANOTHER 1,000 PEOPLE. THE TWO TOWNS COLLABORATE ON MANY COMMUNITY-WIDE INITIATIVES, INCLUDING THE LOCAL SCHOOL SYSTEM. STAPLES BOASTS MANY ATTRACTIVE STORE FRONTS AND BUSINESSES IN THE DOWNTOWN AREA, GIVING IT A "MAIN STREET USA" FEEL. STAPLES IS PROUD OF ITS RICH HISTORY AND ACCOMPLISHMENTS IN THE AREAS OF BUSINESS, EDUCATION, HEALTH CARE, ATHLETICS AND CULTURAL ACTIVITIES. COMMUNITY INVOLVEMENT, PASSION, AND LOYALTY IS ALIVE AND WELL IN STAPLES - FROM THE TOWN RALLYING AROUND LOCAL SPORTS TEAMS, TO ATTENDING CONCERTS AND OTHER FINE ARTS - RELATED EVENTS, TO SUPPORTING LOCAL PHILANTHROPIC EFFORTS, TO CULTURAL ACTIVITIES REPRESENTING THE STRONG SCANDINAVIAN & FINNISH ANCESTRIES IN THE AREA. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE WITHIN LAKEWOOD'S PRIMARY SERVICE AREA.LHS PROVIDES SPECIAL SERVICES INCLUDING PALLIATIVE CARE, MEDICAL HOME, AND HOME HEATLH, FOR THE COMMUNITY. LHS'S EMERGENCY ROOM IS AVAILABLE TO ALL DESPITE PATIENT FINANCIAL IMPLICATIONS. THERE ARE NO LIMITS IN REGARDS TO THE AMOUNT OF CHARITY CARE OR CAP PROGRAM PARTICIPANTS. GOVERNMENT HEALTH SPONSORED PROGRAMS WOULD INCLUDE MEDICARE AND MEDICAID. LHS IS THE SOLE COMMUNITY PROVIDER IN THE STAPLES AREA. PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 MN X X X 0 0 0 0 0 0 0 0 0 TIM RICE 360623 0 0 0 0 0 20446 0 15883 0 396952 0 0 0 JAMES DREGNEY 179906 0 0 0 0 0 19029 0 11923 0 210858 0 0 0 CRAIG WOLHOWE 187620 0 0 0 0 0 20436 0 12407 0 220463 0 0 0 DANIEL DONAHUE 188477 0 0 0 0 0 20077 0 12314 0 220868 0 0 0 LAURIE BACH 192554 0 0 0 0 0 8549 0 12409 0 213512 0 0 0 LYNN NEWTON RICE 187819 0 0 0 0 0 1547 0 11933 0 201299 0 0 0 JEFFREY D OSEGARD 176812 0 0 0 0 0 20350 0 11710 0 208872 0 0 0 ROBERT SCHMIEG 339238 0 0 0 0 0 21600 0 2277 0 363115 0 0 0 SHERREE ENGEN 257098 0 0 0 0 0 20969 0 11411 0 289478 0 0 0 BRIAN L HINMAN 153734 0 0 0 0 0 18821 0 570 0 173125 0 0 0 REBECCA LYNN BENNETT 150935 0 0 0 0 0 20086 0 9569 0 180590 0 0 0 AMY LYNN WINKELS 146199 0 0 0 0 0 19638 0 9987 0 175824 0 0 0 A UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 88903ABXX 2004-12-01 32000000 NEW HOSPITAL CONSTRUCTION 0 0 0 B UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2007-10-31 4800000 SENIOR CAMPUS RENOVATION 0 0 0 C UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2003-09-15 5093625 CONSTRUCTION OF MEDICAL CLINIC AND REFINANCE DEBT 0 0 0 D UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2003-09-15 612000 LAND OF NEW HOSPITAL 0 0 0 A 2495000 32000000 549307 31450693 2006 0 0 1 1 B 842682 4800000 96000 2787440 2011 1 0 1 1 C 1905120 5093625 101872 1275505 3716248 2004 1 0 1 1 D 235426 612000 612000 2004 0 0 1 1 A 0 1 0 0 0.00400 0.00400 0 0 1 B 0 0 0 0 0 0 1 C 0 1 0 0 0.02290 0.02290 0 0 1 D 0 0 0 0 0 0 1 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 1 0 0 0 0 C 0 0 0 0 1 0 0 0 0 D 0 0 0 0 1 0 0 0 0 A 0 B 0 C 0 D 0 FORM 990, SCHEDULE K, PART III, LINE 9 THE ORGANIZATION ESTABLISHED WRITTEN PROCEDURES IN 2013 TO ENSURE THAT ALL NONQUALIFIED BONDS OF THE ISSUE ARE REMEDIATED IN ACCORDANCE WITH THE REQUIREMENTS UNDER REGULATIONS 1.141-12 AND 1.145-2. FORM 990, SCHEDULE K, PART IV, LINE 2 EXPLANATION FOR THE RESPONSE TO LINE 2B FOR QUESTION 2B OF PART IV , THE ORGANIZATION HAS ANSWERED "NO" FOR ALL TAX-EXEMPT BONDS. THERE IS NO REBATE CALCULATION DUE YET. THIS CALCULATION IS ONLY PERFORMED ONCE EVERY 5 YEARS. FORM 990, SCHEDULE K, PART IV, LINE 7 THE ORGANIZATION ESTABLISHED WRITTEN PROCEDURES IN 2013 TO MONITOR THE REQUIREMENTS OF SECTION 148. A UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2009-04-17 3000000 CONSTRUCTION OF MEDICAL CLINIC AND REMODEL OF MEDICAL CLINIC 0 0 0 A 1092516 3000000 60000 2241239 2010 0 0 1 1 A 0 0 0 0 0 0 1 A 0 0 0 0 1 0 0 0 0 A 0 LAKEWOOD CLINIC BOARD MEMBERS HAVE OWNERSHIP INTEREST IN LAKEWOOD CLINIC, PA. 9831367 THE ORGANIZATION HAS A MEDICAL SERVICE AGREEMENT WITH LAKEWOOD CLINIC, PA FOR THE PROVISION OF PHYSICIAN AND OTHER PROFESSIONAL MEDICAL SERVICES. THE AGREEMENT EXPIRES IN 2016. LAKEWOOD CLINIC, PA IS PAID PER A NEGOTIATED PRICE OF RELATIVE VALUE UNIT (RVU). THE RVU IS DETERMINED BASED ON THIRD-PARTY COMPENSATION DATA. IN ADDITION, THERE ARE COMPENSATION AGREEMENTS FOR SERVICES THAT USE HOURLY RATES DETERMINED USING MARKET DATA TO ENSURE COMPENSATION IS REASONABLE. THERE ARE SPECIALIST POSITIONS THAT RECEIVE AN ANNUAL COMPENSATION THAT IS ALSO DETERMINED USING MARKET DATA. THE FOLLOWING LAKEWOOD HEALTH SYSTEM BOARD MEMBERS HAVE OWNERSHIP IN LAKEWOOD CLINIC, PA: -CHRISTINE ALBRECHT MD -JULIE BENSON MD-SARAH ISRAELSON MD-WILLIAM MENNIS MD 0 FORM 990, PART VI, SECTION A, LINE 2 TIM RICE, PRESIDENT/CEO, IS MARRIED TO LYNN NEWTON RICE, DIVISION DIRECTOR. FORM 990, PART VI, SECTION B, LINE 11 THE PREPARER OF FORM 990 EMAILS A COPY OF THE FINAL 990 TO THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. THE CHIEF FINANCIAL OFFICER PERFORMS A DETAIL REVIEW OF FORM 990. THE CHIEF FINANCIAL OFFICER PROVIDES EACH VOTING BOARD MEMBER WITH A COPY OF FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANY INTERESTS WHICH WERE IDENTIFIED AS PART OF THE ANNUAL CONFLICT OF INTEREST DISCLOSURE WOULD BE DOCUMENTED IN THE BOARD OF DIRECTOR MEETING MINUTES. FOR ANY BOARD ACTION THAT REQUIRED A VOTE AND COULD BE INFLUENCED BY A CONFLICT, THE AFFECTED BOARD MEMBER IS NOT PERMITTED TO VOTE ON THE ACTION. THE OFFICERS, DIRECTORS, AND KEY EMPLOYEES COMPLETE A FORMAL CONFLICT OF INTEREST DISCLOSURE ANNUALLY. THE ORGANIZATION ALSO CONSIDERS WHETHER OTHER POTENTIAL CONFLICTS OF INTEREST COULD RESULT FOR ANY OF THESE INDIVIDUALS BASED ON POSSIBLE ACTIONS UNDER CONSIDERATION BY THE ORGANIZATION DURING THE YEAR. FORM 990, PART VI, SECTION B, LINE 15 FOR THE CEO, INITIAL COMPENSATION CONSIDERATION IS MADE BASED ON A REVIEW OF SALARY SURVEY DATA COMPILED BY THE MINNESOTA HOSPITAL ASSOCIATION. THIS DATA IS THEN REVIEWED BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. AFTER THIS REVIEW, THE DATA IS SUBMITTED TO THE FULL FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW ALONG WITH THE ENTIRE ANNUAL BUDGET PACKAGE. FINALLY, THE FULL BUDGET PACKAGE, ALONG WITH ALL SPECIFIC SALARY PROPOSALS ARE SUBMITTED TO THE FULL BOARD OF DIRECTORS FOR FINAL APPROVAL. AT ANY TIME IN THIS PROCESS, ANY OF THE COMMITTEES OR BOARD COULD REQUEST ADDITIONAL INDEPENDENT SALARY INFORMATION SUPPORTING THE PROPOSED SALARY. A FIRM NAMED CLARK CONSULTING IS USED TO PROVIDE ADDITIONAL CEO COMPENSATION DATA. THIS COMPENSATION AMOUNT IS INCLUDED IN THE CEO EMPLOYMENT CONTRACT WHICH IS PREPARED EACH YEAR WITH A ONE YEAR TERM. FOR THE CFO AND THE OTHER DIVISION DIRECTORS, THE PROCESS IS THE SAME EXCEPT THAT THE INDEPENDENT EXTERNAL DATA TYPICALLY STARTS WITH WHAT CLARK CONSULTING PROVIDES. ADDITIONALLY, WE HAVE INCLUDED THE MHA SALARY SURVEY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THESE DOCUMENTS CAN BE REQUESTED FROM THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTIONS -13,604. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. MEDICAL SPA LLC 49725 CTY 83 STAPLES MN 56479 800807773 DERMATOLOGY CLINIC AND MEDICAL SPA MN N/A RELATED 24226 159647 0 1 0.50000 LAKEWOOD-CENTRACARE LLC 49725 CTY 83 STAPLES MN 56479 411974939 CLINICAL SERVICES MN N/A RELATED 18478 -55501 0 1 0.50000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0