2013-05-14T09:56:52-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 411924645 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE CENT 3207322141 20 SE NINTH STREET LONG PRAIRIE MN 56347 ERIC LOHN 3207322141 2013-05-08 1 KOREY BOELTER P00775161 6123764500 2011 2016-02-24 21:20:13Z JAMES DAVIS 20 SE NINTH STREET LONG PRAIRIE MN 56347 24078203 0 X WWW.CENTRACARE.COM X 1999 MN TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE COMMUNITY. 5 0 286 75 0 0 28517 33537 23797199 23370646 445085 375418 191354 292479 24462155 24072080 204802 536745 0 0 14268532 14844682 0 0 0 9059965 8781926 23533299 24163353 928856 -91273 19640698 19395442 5077823 5168512 14562875 14226930 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE PROVIDES QUALITY HEALTH CARE WITH COMPASSION, DIGNITY, INTEGRITY, AND RESPECT SHOWN TO ALL CUSTOMERS AND EMPLOYEES. 0 0 16936197 536745 23370646 THE ORGANIZATION IS DEDICATED TO THE CONCEPT OF PROVIDING RESIDENTS OF LONG PRAIRIE AND THE SURROUNDING AREA WITH QUALITY HEALTH CARE FOR INPATIENT, OUTPATIENT, EMERGENCY CARE, AND NURSING HOME CARE. THE ORGANIZATION PROVIDED $2,618,764 OF COMMUNITY BENEFIT AND CONTRIBUTIONS DURING THE YEAR THROUGH HOSPITAL SERVICES, A HEALTH FAIR, A BLOODMOBILE AND OTHER ACTIVITIES. 16936197 1 0 0 0 0 1 0 0 1 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 34 0 286 1 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X LARRY KNUTSON 3207327240 20 SOUTHEAST NINTH STREET LONG PRAIRIE MN 56347 X JAMES DAVIS 1.00 X 0 380588 36682 ALLEN HORN MD 1.00 X 0 587816 114083 GREGORY KLUGHERZ 1.00 X 0 524194 106835 TERENCE PLADSON MD 1.00 X 0 948477 213721 PAUL HARRIS 1.00 X 0 307893 83406 DANIEL SWENSON 40.00 X 0 216883 48786 ERIC LOHN 13.00 X 0 189382 22576 JAMES BERGMANN 40.00 X 167161 0 26805 THOMAS HOCK 40.00 X 146234 0 35883 MARK CHRISTIANSEN 40.00 X 134193 0 12491 CHRISTOPHER HAGEN 40.00 X 123017 0 25561 CHRISTINE OLSON 40.00 X 115904 0 19703 JOHN SECKINGER 0.00 X 0 283393 0 686509 3438626 746532 9 1 1 0 CENTRACARE CLINIC 1200 6TH AVENUE NORTH ST CLOUD MN 56303 PHYSICIAN SERVICES 1766619 CENTRACARE HEALTH SYSTEM - MELROSE 11 NORTH 5TH AVENUE WEST MELROSE MN 56352 BILLING SERVICES 322070 WEST CENTRAL ANESTHESIA PC 10382 AUGUSTA DRIVE SAUK CENTRE MN 56378 CRNA SERVICES 232239 3 32866 671 33537 PATIENT REVENUES 621110 22973496 22973496 JOINT VENTURE REVENUES 621110 216653 216653 PHARMACY INCOME 621110 180497 180497 23370646 6843 6843 41188 0 41188 41188 41188 373198 1500 0 6123 373198 -4623 368575 368575 MISCELLANEOUS 900099 198551 198551 MEAL INCOME 900099 52740 52740 251291 24072080 23370646 0 667897 533222 533222 3523 3523 10698117 7852126 2845991 457866 320171 137695 3024271 2109877 914394 664428 496002 168426 46820 46820 94386 94386 1537438 1248398 289040 4646 199 4447 1199047 814090 384957 389705 57168 332537 539777 161550 378227 94233 48658 45575 479 365 114 151246 150564 682 757309 757309 104141 65554 38587 MEDICAL SUPPLIES 2045041 1919286 125755 BAD DEBTS 699910 171289 528621 MEDICAID SURCHARGE 316948 316948 FOOD 226875 37220 189655 573925 189626 384299 24163353 16936197 7227156 0 1683007 1788867 3571565 3347382 337456 312449 151641 173785 15096699 7628367 6858345 7468332 5910645 5554750 696196 632363 431843 117514 19640698 19395442 1848224 1916671 18641 17021 8508 6724 2611293 2535244 591157 692852 5077823 5168512 X 14539511 14203003 23364 23927 14562875 14226930 19640698 19395442 X -91273 -244672 X 0 1 1 X 0 X 1 757 250 23928 1 1 0 1 312427 312427 8824116 3500573 5323543 279639 121142 158497 5680517 4006652 1673865 7468332 ASSETS INTERNALLY DESIGNATED FOR CAPITAL ACQUISITIONS 5554750 F 5554750 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 160000 ASSET RETIREMENT OBLIGATION 102799 DUE TO AFFILIATES 430053 692852 24072080 24163353 -91273 -244672 -244672 -335945 23663125 -244672 -244672 23907797 164283 164283 24072080 23630131 0 23630131 533222 533222 24163353 PART IV, LINE 2B: RESIDENT TRUST FUNDS ARE HELD BY THE ORGANIZATION ON BEHALF OF THE RESIDENTS IN A SEPARATE BANK ACCOUNT. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION IS A NOT FOR PROFIT ORGANIZATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. THE TAX RETURNS FOR THE YEARS 2008 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. THE ORGANIZATION FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE ORGANIZATION'S FINANCIAL STATEMENTS. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT INCOME - OPERATING 32,866. INVESTMENT INCOME 135,369. RESTRICTED CONTRIBUTIONS 563. LOSS ON SALE OF ASSETS -4,623. UNRESTRICTED CONTRIBUTIONS 108. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION TO CENTRACARE FOUNDATION 50,000. TRANSFER TO CENTRACARE HEALTH SYSTEM 483,222. 1 1 X 1 X 175.000000000000 1 X 1 1 1 0 1 1 663320 663320 0.02750 3169708 1954974 1214734 0.05030 3833028 1954974 1878054 0.07780 10918 10918 0.00050 1078253 1078253 0.04460 331 331 0.00000 1089502 1089502 0.04510 4922530 1954974 2967556 0.12290 1 699910 179611 5673345 5577481 95864 X 1 1 1 1 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE

20 SOUTHEAST NINTH STREET LONG PRAIRIE MN 56347

X X X X SNF & PROVIDER BASED RURAL HEALTH CLINIC CENTRACARE HEALTH SYSTEM - LONG PRAIRIE 1 1 1 175.000000000000 1 250.000000000000 1 X 1 1 X X X 1 0 1 X 0 0 3 CCHS - LP NURSING HOME

20 SE NINTH STREET LONG PRAIRIE MN 56347

SKILLED NURSING FACILITY CCHS - LONG PRAIRIE CLINIC

20 SE NINTH STREET LONG PRAIRIE MN 56347

PROVIDER BASED RURAL HEALTH CLINIC CCHS - LP EAGLE VALLEY CLINIC

815 HIGHWAY 71 SOUTH EAGLE BEND MN 56446

PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 7: THE COSTING METHODOLOGY USED WAS DERIVED FROM THE COST TO CHARGE RATIO BASED ON WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LINE 7G: THE SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDES CCHS-LP'S SKILLED NURSING FACILITY LOSS OF $1,078,253. THIS WAS CALULATED BY THE DIFFERENCE BETWEEN THE MEDICARE COST REPORT WORKSHEET D-1, PART 1 SNF CHARGES LESS COST. PART I, L7 COL(F): IN THE CALCULATION OF THE AMOUNTS INCLUDED IN PART I, LINE 7, COLUMN F THERE WAS $699,910 OF BAD DEBT EXPENSE ELIMINATED. PART III, LINE 4: THE FOLLOWING IS FROM THE "ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:THE ORGANIZATION PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE SELF-PAY AND MISCELLANEOUS COMMERCIAL INSURANCE ACCOUNTS. PAYMENTS FOR SERVICES IS REQUIRED UPON RECEIPT OF AN INVOICE, AFTER PAYMENT BY INSURANCE, IF ANY. SELF-PAY ACCOUNTS ARE ANALYZED FOR COLLECTIBILITY BASED ON THE MONTHS PAST DUE AND PAYMENT HISTORY. AN ALLOWANCE IS ESTIMATED FOR THESE ACCOUNTS BASED ON THE HISTORICAL EXPERIENCE OF THE ORGANIZATION. THE AMOUNT AT BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNT CHARGES AND PER DIEM RATES. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED IN PART III, LINE 6 IS DERIVED FROM THE ORGANIZATION'S 2012 FILED MEDICARE COST REPORT.THERE WAS NO SHORTFALL CALCULATED IN PART III, LINE 7. THE SURPLUS IS REASONABLE GIVEN THE FACT THAT CENTRACARE HEALTH SYSTEM - LONG PRAIRIE IS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED BY MEDICARE AT COST PLUS 1%. PART III, LINE 9B: THE ORGANIZATION'S COLLECTION POLICY REQUIRES THE COLLECTION STAFF TO OFFER CHARITY CARE TO PATIENTS WHO INDICATE THAT PAYMENT FOR SERVICES PROVIDED BY OUR FACILITY MIGHT BE AN ISSUE. IF A PATIENT QUALIFIES FOR FULL CHARITY, ALL OTHER COLLECTION EFFORTS CEASE. IF A PATIENT QUALIFIES FOR PARTIAL CHARITY, COLLECTION EFFORTS WILL CONTINUE ON THE BALANCE OF THE ACCOUNT. THIS POLICY APPLIES TO BOTH FACILITY BASED OR CONTRACTED AGENCY COLLECTION STAFF. NO PATIENTS, WHETHER THEY QUALIFY FOR CHARITY OR NOT, ARE REPORTED TO CREDIT RATING AGENCIES. CENTRACARE HEALTH SYSTEM - LONG PRAIRIE PART V, SECTION B, LINE 13G: A COPY OF THE PATIENT FINANCIAL SERVICES BROCHURE IS INCLUDED IN THE HOSPITAL INPATIENT PACKET OF INFORMATION WHICH IS PROVIDED IN EACH PATIENT ROOM. CENTRACARE HEALTH SYSTEM - LONG PRAIRIE PART V, SECTION B, LINE 17E: OUR COLLECTION AGENCIES ARE REQUIRED TO PROVIDE CHARITY INFORMATION AS PART OF THEIR COLLECTION PROCESS PRIOR TO ANY CONSIDERATION OF LEGAL ACTION AGAINST THE PATIENT. CENTRACARE HEALTH SYSTEM - LONG PRAIRIE PART V, SECTION B, LINE 19D: PER THE AGREEMENT WITH THE STATE OF MINNESOTA ATTORNEY GENERAL, THE ORGANIZATION PROVIDES A DISCOUNT TO THE UNINSURED AND LOW-INCOME INSURED EQUAL TO THE AVERAGE DISCOUNT OF OUR LARGEST (BY VOLUME) NON-GOVERNMENTAL PAYOR. PART VI, LINE 2: THE ORGANIZATION'S STRATEGIC PLAN INCLUDES ASSESSING THE NEEDS OF THE COMMUNITY AND PATIENTS THROUGH PATIENT SATISFACTION SURVEYS, COMMENT CARDS, COMMUNITY ASSESSMENTS AND A DIVERSE GOVERNING BOARD THAT REPRESENTS THE COMMUNITY AND BRINGS TO THE TABLE ISSUES, CONCERNS, RECOMMENDATIONS FOR HEALTH CARE SERVICES. PART VI, LINE 3: THE ORGANIZATION'S ADMISSIONS AND BILLING STAFF COMMUNICATE VERBALLY OR VIA LETTER REGARDING OUR CHARITY CARE AND VARIOUS FEDERAL, STATE, AND LOCAL ASSISTANCE PROGRAMS. PART VI, LINE 4: THE COMMUNITY OF LONG PRAIRIE AND THE SURROUNDING AREA CONSISTS OF APPROXIMATELY 3,458 PEOPLE. THE 2010 DEMOGRAPHIC INFORMATION INDICATES A SENIOR POPULATION (60 YEARS OR OLDER) MAKES UP 17.4% OF THE TOTAL MARKET POPULATION. THE PER CAPITA INCOME OF THE RESIDENTS IN OUR AREA IS EXTREMELY DEPRESSED AT $21,390 COMPARED TO A STATE AVERAGE OF $29,431. TODD COUNTY IS RANKED 86TH, OR SECOND TO THE LAST, IN PER CAPITA INCOME IN THE STATE OF MINNESOTA. PART VI, LINE 5: ONE OF THE LARGER COMMUNITY BUILDING ACTIVITIES THE ORGANIZATION IS INVOLVED IN IS A HOSTING A COMMUNITY HEALTH FAIR THAT OFFERS FREE SCREENINGS, EDUCATION BOOTHS AND HEALTH INFORMATION TO OUR AREA. MANY OTHER SPECIALTY CLINICS ARE INVOLVED TO OFFER EDUCATION ON THEIR TOPICS. OUR HOSPITAL ALSO PUTS ON MANY SMALL BUSINESS HEALTH FAIRS. WE GO INTO THE BUSINESS AND OFFER FREE SCREENINGS AND ASSESSMENTS TO THEIR EMPLOYEES. THE GOAL IS TO KEEP EMPLOYEES SAFE AND HEALTHY. ALSO, QUARTERLY FREE SCREENINGS ARE AVAILABLE THROUGH OUR FACILITY AT THE LOCAL GROCERY STORE. THE ORGANIZATION ALSO PROMOTES HEALTH CARE RELATED JOBS EDUCATION TO THE STUDENTS IN THE COMMUNITY. EACH SPRING AND FALL, IN CONJUNCTION WITH THE LOCAL HIGH SCHOOL, WE OFFERED A JUNIOR/SENIOR HEALTH CARE CAREERS CLASS WHICH INCLUDES JOB SHADOWING ON SITE. STAFF PARTICIPATES IN COMMUNITY ORGANIZATIONS TO PROVIDE HEALTHCARE REPRESENTATION AND INFORMATION TO ENHANCE THOSE ORGANIZATIONS EVENTS, INCLUDING THE LONG PRAIRIE CHAMBER OF COMMERCE, THE LONG PRAIRIE TRAILS COMMITTEE, PRAIRIEFEST, ETC. THE BE A LOSER WELLNESS CHALLENGE IS A COMMUNITY BASED PROJECT THAT THE ORGANIZATION PARTICIPATED IN TO SUPPORT HEALTHY LIFESTYLES. THE ORGANIZATION OFFERS REGULAR CPR CLASSES TO AREA SCHOOL STUDENTS AS WELL AS THE PUBLIC. THE CLASS OFFERS CPR TRAINING TO BECOME CERTIFIED IN CPR. THE ORGANIZATION PARTICIPATES WITH THE MULTI-SPECIALTY CLINIC AND HEALTH SYSTEM LEADERSHIP WITHIN OUR OVERALL ORGANIZATION IN PROVIDING ACCESS TO CARE, SUPPORT GROUPS, EDUCATIONAL ACTIVITIES, AND FINANCIAL CONTRIBUTIONS TO OUR AREA. THE ORGANIZATION RE-INVESTS ITS PROFITS BACK INTO EQUIPMENT AND SERVICES FOR THE HOSPITAL AND TO BENEFIT THE COMMUNITY IT SERVES. THIS ENSURES THE COMMUNITY CAN STAY CLOSE TO HOME FOR ITS SERVICES. THE ORGANIZATION OFFERS CHILD PREPARATION AND BREASTFEEDING CLASSES TO EXPECTING PARENTS IN THE AREA. THE CLASSES COVER THE LABOR AND BIRTH PROCESS, BREATHING AND RELAXATION TECHNIQUES, COMMON INTERVENTIONS, CAESAREAN BIRTHS, PAIN MEDICATION AND THE BENEFITS OF BREASTFEEDING. THESE CLASSES ARE ALSO AVAILABLE IN SPANISH TO ACCOMODATE OUR HISPANIC POPULATION. PART VI, LINE 6: THE ORGANIZATION IS PART OF CENTRACARE HEALTH SYSTEM (CCHS) WHICH PROVIDES A BROAD RANGE OF HEALTH CARE SERVICES TO THE PATIENTS OF CENTRAL MINNESOTA. CCHS IS DEDICATED TO IMPROVING THE HEALTH OF PEOPLE LIVING AND WORKING IN THE COMMUNITIES IT SERVES. TO ACCOMPLISH ITS GOALS IT WORKS ACTIVELY WITH ITS AFFILIATE HEALTH CARE ORGANIZATIONS. CCHS CONTINUES TO FOCUS ON PROVIDING THE BEST CARE POSSIBLE AND IN REINVESTING INTO THE COMMUNITY. CCHS ALSO PROMOTES WELLNESS BY SPONSORING PROGRAMS AND EVENTS IN LOCAL COMMUNITIES THAT FOCUS ON HEALTHY EATING AND EXERCISE, AND BY CONDUCTING SCREENINGS FOR CONDITIONS SUCH AS HIGH BLOOD PRESSURE. REPORTS FILED WITH STATES PART VI, LINE 7 MN 1 CENTRACARE HEALTH FOUNDATION 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411855173 501(C)(3) 50000 TO SUPPORT GENERAL OPERATIONS CENTRACARE HEALTH SYSTEM 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411813221 501(C)(3) 483222 TO SUPPORT GENERAL OPERATIONS 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: CENTRACARE HEALTH SYSTEM IS A NOT-FOR-PROFIT CORPORATION 501(C)(3)THAT PROVIDES A COMPREHENSIVE PROGRAM OF HEALTH CARE SERVICES TO THE RESIDENTS OF CENTRAL MINNESOTA. AS PART OF THIS HEALTHFOCUSED MISSION, CENTRACARE HEALTH SYSTEM PROVIDES A LIMITED NUMBER OF CHARITABLE CONTRIBUTIONS TO ORGANIZATIONS THAT IMPROVE THE HEALTH OF CENTRAL MINNESOTANS. THE MAJORITY OF CONTRIBUTIONS ARE MADE IN THE FORM OF GRANTS THROUGH THE CENTRACARE HEALTH FOUNDATION. THE FOUNDATION'S GRANTS COMMITTEE REVIEWS FUNDING APPLICATIONS FROM PROGRAMS THROUGHOUT THE REGION. HOWEVER, THE CENTRACARE CONTRIBUTIONS COMMITTEE FUNCTIONS TO STREAMLINE HEALTH-RELATED CHARITABLE CONTRIBUTIONS THAT DO NOT FALL WITHIN THE FOUNDATION'S GUIDELINES. THIS POLICY OUTLINES THE PROCEDURES TO BE FOLLOWED AND THE CRITERIA TO BE CONSIDERED IN EVALUATING REQUESTS FOR FUNDING. CONTRIBUTIONS MUST BE IN KEEPING WITH THE MISSION OF CENTRACARE HEALTH SYSTEM, WHICH IS TO WORK TO IMPROVE THE HEALTH OF EVERY PATIENT, EVERY DAY. CONTRIBUTIONS WILL BE MADE TO ORGANIZATIONS RATHER THAN TO INDIVIDUALS WITHIN THE CENTRAL MINNESOTA REGION. CENTRACARE'S CHARITABLE FUNDS MAY NOT BE USED TO SUPPORT ANY ORGANIZATION OR EVENT THAT WOULD RESULT IN BENEFITS OF ANY KIND TO AN EMPLOYEE OF THE HEALTH SYSTEM OR A MEMBER OF THE VARIOUS BOARDS OF DIRECTORS, EITHER DIRECTLY OR INDIRECTLY. ONE EXCEPTION EXISTS TO THE GUIDELINE REGARDING BENEFIT TO EMPLOYEES: WE WILL SUPPORT, VIA SCHOLARSHIPS AND THE PURCHASE OF SUPPLIES, THE MEDICAL MISSION WORK OF OUR STAFF AND PHYSICIANS. THE CENTRACARE HEALTH SYSTEM CONTRIBUTIONS COMMITTEE IS MADE UP OF: ONE REPRESENTATIVE FROM CENTRACARE HEALTH FOUNDATION; ONE REPRESENTATIVE FROM ST. CLOUD HOSPITAL HUMAN RESOURCES; THE DIRECTOR OF CENTRACARE HEALTH SYSTEM'S COMMUNICATIONS DEPARTMENT AND THE COMMUNICATIONS/MARKETING SPECIALIST RESPONSIBLE FOR CENTRACARE CLINIC; THE DIRECTOR OF CENTRACARE HEALTH SYSTEM'S MARKETING/PLANNING DEPARTMENT; THE DIRECTOR OF ST. CLOUD HOSPITAL VOLUNTEER SERVICES; AND SI. CLOUD HOSPITAL'S DIRECTOR OF MISSION & SPIRITUAL CARE. THE COMMITTEE MEETS MONTHLY TO ENSURE A STREAMLINED, COORDINATED PROCESS OF REVIEWING REQUESTS AND DETERMINING FUNDING. THE COMMITTEE MAINTAINS A DATABASE TO TRACK ALL CONTRIBUTIONS. OTHER CENTRACARE ENTITIES, INCLUDING CENTRACARE HEALTH SYSTEM - LONG PRAIRIE, CENTRACARE HEALTH SYSTEM - MELROSE, AND ST BENEDICT'S SENIOR COMMUNITY MAY DEVELOP A BUDGET FOR APPROVAL AND IMPLEMENT THEIR OWN CONTRIBUTIONS DECISIONS WITHIN THE GUIDELINES OF THIS DOCUMENT. CONTRIBUTIONS MAY NOT EXCEED THE STATED BUDGET AND NO MULTI-YEAR COMMITMENTS TO ORGANIZATIONS MAY BE MADE WITHOUT APPROVAL FROM THE CENTRACARE HEALTH SYSTEM EXECUTIVE COUNCIL. INDIVIDUALS AND DEPARTMENTS FROM THROUGHOUT ST CLOUD HOSPITAL AND THE CENTRACARE CLINIC SITES IN ST. CLOUD SHOULD FORWARD ALL OUTSIDE FUNDING REQUESTS TO A MEMBER OF THE COMMITTEE FOR THE FULL GROUP'S CONSIDERATION. THOSE REQUESTING FUNDS SHOULD BE ASKED TO SUBMIT THEIR REQUEST IN WRITING. 0 1 0 0 0 0 1 0 0 JAMES DAVIS 0 278990 0 52884 0 48714 0 15380 0 21302 0 417270 0 0 ALLEN HORN MD 0 357539 0 94541 0 135736 0 86878 0 27205 0 701899 0 0 GREGORY KLUGHERZ 0 368764 0 76230 0 79200 0 87297 0 19538 0 631029 0 0 TERENCE PLADSON MD 0 745962 0 191627 0 10888 0 194986 0 18735 0 1162198 0 0 PAUL HARRIS 0 250007 0 55565 0 2321 0 47172 0 36234 0 391299 0 0 DANIEL SWENSON 0 164181 0 36256 0 16446 0 23492 0 25294 0 265669 0 0 ERIC LOHN 0 165760 0 16892 0 6730 0 13895 0 8681 0 211958 0 0 JAMES BERGMANN 151148 0 14880 0 1133 0 12549 0 14256 0 193966 0 0 0 THOMAS HOCK 143193 0 2628 0 413 0 11051 0 24832 0 182117 0 0 0 JOHN SECKINGER 0 0 0 0 0 283393 0 0 0 0 0 283393 0 0 PART I, LINE 4B 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: - RECEIVED DISTRIBUTION OF 457(F): - GREGORY KLUGHERZ - $74,990 - DANIEL SWENSON - $14,817 - ALLEN HORN - $51,443 - JOHN SECKINGER - $283,393 - ACCRUED 457(F) EARNINGS: - GREGORY KLUGHERZ - $75,047 - TERENCE PLADSON - $176,611 - DANIEL SWENSON - $14,306 - PAUL HARRIS - $37,166 - ALLEN HORN - $53,154 PART I, LINE 6 THE ORGANIZATION PROVIDES INCENTIVE COMPENSATION TO DESIGNATED INDIVIDUALS BASED ON FOUR DISCRETE AREAS: A COMPARISON BETWEEN BUDGETED AND ACTUAL NET OPERATING INCOME FOR CENTRACARE HEALTH SYSTEM; ACHIEVEMENT OF IMPROVEMENT IN PATIENT SATISFACTION GOALS AS COMPARED TO NATIONAL AND BASELINE RANKINGS; ACHIEVEMENT OF IMPROVEMENT IN OVERALL EMPLOYMENT ENGAGEMENT SCORES; AND ACHIEVEMENT OF UP TO THREE INDIVIDUAL GOALS WHICH ARE TIED TO THE CENTRACARE SYSTEM'S STRATEGIC PLAN. SUPPLEMENTAL INFORMATION PART III THE COMPENSATION PAID TO THE PRESIDENTS AND VICE-PRESIDENTS (NON-MEDICAL PROVIDERS) IS DETERMINED BY CENTRACARE HEALTH SYSTEM, A RELATED ORGANIZATION. CENTRACARE HEALTH SYSTEM USES THE FOLLOWING METHODS TO DETERMINE THEIR COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYEMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 6 CENTRACARE HEALTH SYSTEM, A MINNESOTA NONPROFIT ASSOCIATION, IS THE SOLE MEMBER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A ALL BOARD MEMBERS ARE APPOINTED BY CENTRACARE HEALTH SYSTEM, THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MATTERS ARE RESERVED FOR ACTION BY CENTRACARE HEALTH SYSTEM, THE SOLE MEMBER: 1. ADOPTION OR AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS. 2. APPOINTMENT OF DIRECTORS AND OFFICERS. 3. APPROVAL OF THE CORPORATION'S ANNUAL OPERATING AND CAPITAL BUDGETS AND ANY DEBTS TO BE INCURRED. 4. APPROVAL OF ALL STRATEGIC PLANS. 5. DETERMINATION OF THE DISSOLUTION OF OR THE DISCONTINUATION OF THE BUSINESS OF THE CORPORATION. 6. APPROVAL OF ANY TRANSACTION WHICH MAY AFFECT THE CORPORATION'S STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAXATION. FORM 990, PART VI, SECTION B, LINE 11 ANNUALLY, AT THE BOARD OF DIRECTORS' MEETING, PRIOR TO FILING, THE FULL BOARD HAS AN OPPORTUNITY TO REVIEW THE IRS FORM 990 WITH STAFF TO ASK QUESTIONS AND SEEK CLARIFICATIONS AND TO APPROVE THE FINAL DOCUMENT. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICTS OF INTEREST QUESTIONNAIRE ON A BI-ANNUAL BASIS. ALL STAFF SIGNS CONFLICTS OF INTEREST FORMS ON AN ANNUAL BASIS. THE QUESTIONNAIRES ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AS WELL AS THE CORPORATE COMPLIANCE GROUP (A COMPLIANCE COMMITTEE WHICH INCLUDES INTERNAL MEMBERS AND OUTSIDE COUNSEL). THE RESPONSES TO THE QUESTIONNAIRES ARE REVIEWED WITH THE EXECUTIVE COMMITTEE OF THE BOARD. THE CORPORATE COMPLIANCE OFFICER IS RESPONSIBLE FOR MONITORING CONFLICTS OF INTERESTS RELATED TO BOARD AND STAFF, AND TO ALERT AFFECTED PARTIES WHEN A CONFLICT ARISES. WHEN AN ACTUAL CONFLICT ARISES, THE AFFECTED PARTY IS ASKED TO RECUSE HIM- OR HERSELF FROM THE DECISION MAKING PROCESS. THE CORPORATE COMPLIANCE OFFICER ATTENDS BOARD MEETINGS AND SPECIFIED BOARD COMMITTEE MEETINGS WHERE CONFLICT ISSUES MAY ARISE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST AND ARE ALSO REPORTED PUBLICLY IN THE FORM 990. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -244,672. AVERAGE WEEKLY HOURS FORM 990, PART VII, SECTION A THE COMPENSATED OFFICERS AND BOARD MEMBERS OF CENTRACARE HEALTH SYSTEM - LONG PRAIRIE SERVE MULTIPLE RELATED ORGANIZATIONS. EACH INDIVIDUAL WORKS APPROXIMATELY 40 HOURS PER WEEK ACROSS THE RELATED ORGANIZATIONS. CENTRACARE HEALTH SYSTEM 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411813221 HEALTH CARE MN 501(C)(3) 11 - TYPE 3 FI N/A 0 CENTRACARE HEALTH SYSTEM - MELROSE 11 NORTH 5TH AVENUE WEST MELROSE MN 56352 411865315 ACUTE & LONG-TERM CARE MN 501(C)(3) 3 CCHS 0 CENTRAL MINNESOTA EMERGENCY PHYSICIANS 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411708142 EMERGENCY PHYSICIAN PRACTICE MN 501(C)(3) 3 N/A 0 CENTRACARE CLINIC 1200 6TH AVENUE NORTH ST CLOUD MN 56303 411806657 MULTI-SPECIALTY PHYSICIAN CLINIC MN 501(C)(3) 3 CCHS 0 CENTRACARE HEALTH FOUNDATION 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411855173 FUNDRAISING MN 501(C)(3) 7 N/A 0 CENTRACARE PHARMACY SERVICES INC 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411620618 RETAIL PHARMACY MN N/A C 0 1 0 0 1 0 0 0 0 1 0 1 0 1 1 1 1 0