2013-09-30T09:31:49-05:00 2012-12-31 990 2012-01-01 204156428 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS MAYO 5075381297 1116 WEST MILL STREET CANNON FALLS MN 55009 EDWARD TUSA 5072634221 2013-09-27 2012 2016-02-24 21:20:13Z THOMAS J WITT MD 1116 WEST MILL STREET CANNON FALLS MN 55009 23263637 0 X WWW.MAYOCLINICHEALTHSYSTEM.ORG X 2006 MN OPERATION OF HOSPITAL AND CLINIC. 9 4 237 24 0 0 376427 1070973 18336170 22086437 23293 -40059 35087 58405 18770977 23175756 3000 9624 0 0 10547652 12514185 0 65000 65000 7909702 8267858 18460354 20856667 310623 2319089 15962247 18663160 2094047 1632453 13868200 17030707 X TO INSPIRE HOPE AND CONTRIBUTE TO HEALTH AND WELL-BEING BY PROVIDING THE BEST CARE TO EVERY PATIENT THROUGH INTEGRATED CLINICAL PRACTICE, EDUCATION, AND RESEARCH. 0 0 17275228 22023915 PATIENT SERVICES (HOSPITAL & CLINIC) - SEE SCHEDULE OMAYO CLINIC HEALTH SYSTEM IS A FAMILY OF CLINICS, HOSPITALS AND HEALTH CARE FACILITIES SERVING COMMUNITIES IN MINNESOTA, IOWA AND WISCONSIN. AS PART OF MAYO CLINIC, MAYO CLINIC HEALTH SYSTEM OFFERS OUTSTANDING CARE CLOSE TO HOME. PHYSICIANS AND STAFF IN MAYO CLINIC HEALTH SYSTEM HAVE READY ACCESS TO THE KNOWLEDGE, RESOURCES, AND EXPERTISE OF MAYO CLINIC, YET CAN MEET PATIENTS' HEALTH CARE NEEDS LOCALLY. MAYO CLINIC HEALTH SYSTEM IS PART OF THE COMMUNITY, FOCUSED ON IMPROVING THE HEALTH OF THE COMMUNITIES IN WHICH WE LIVE AND WORK. MAYO CLINIC HEALTH SYSTEM TEAMS WITH MAYO CLINIC TO DELIVER UNPARALLELED HEALTH CARE TO COMMUNITIES THROUGH AN INTEGRATED NETWORK OF CLINICS AND HOSPITALS.IN 2012, MAYO CLINIC HEALTH SYSTEM SITES EMPLOYED APPROXIMATELY 900 PHYSICIANS AND 13,000 ALLIED HEALTH STAFF. IN ADDITION, MAYO CLINIC PHYSICIANS FROM MULTIPLE SPECIALTIES REGULARLY SEE PATIENTS AT THE MAYO CLINIC HEALTH SYSTEM FACILITIES. BESIDES HAVING HEALTH CARE FACILITIES IN 72 COMMUNITIES, THE SYSTEM INCLUDES 18 OWNED HOSPITALS, SEVEN OWNED NURSING HOMES, PHYSICIAN SERVICE AGREEMENTS WITH TWO ADDITIONAL HOSPITALS, AND CONTRACT MANAGEMENT AGREEMENTS WITH AN ADDITIONAL HOSPITAL AND NURSING HOME. SINCE ITS INCEPTION IN 1992, MAYO CLINIC HEALTH SYSTEM HAS GROWN FROM A NEW IDEA TO ONE OF THE MOST SUCCESSFUL REGIONAL HEALTH CARE SYSTEMS IN AMERICA. MAYO CLINIC HEALTH SYSTEM COMPLETES MORE THAN TWO-MILLION PATIENT VISITS ANNUALLY. IT ALSO SERVES AS A NATIONAL LEADER IN QUALITY AND SAFETY EFFORTS BEING RECOGNIZED SIX TIMES BY THE AMERICAN MEDICAL GROUP ASSOCIATION'S ACCLAIM AWARD PROGRAM (2005 ACCLAIM AWARD RECIPIENT AND FIVE-TIME ACCLAIM AWARD HONOREE). THE ACCLAIM AWARDS HONOR PHYSICIAN-LED ORGANIZATIONS DELIVERING CARE ALIGNED WITH THE IDEAL DELIVERY MODEL WHERE PATIENTS EXPERIENCE SAFE, RELIABLE, RESPONSIVE, READILY AVAILABLE AND INTEGRATED CARE. IN ADDITION, THE MINNESOTA COUNCIL FOR QUALITY HAS RECOGNIZED MAYO CLINIC HEALTH SYSTEM THREE TIMES FOR ITS PERFORMANCE EXCELLENCE EFFORTS. INDIVIDUAL MAYO CLINIC HEALTH SYSTEM LOCATIONS HAVE ALSO BEEN HONORED FOR THEIR COMMITMENT TO QUALITY, SAFETY, SERVICE, PERFORMANCE AND THEIR COMMUNITIES.PEOPLE IN MINNESOTA, IOWA AND WISCONSIN CAN HAVE PEACE OF MIND KNOWING THAT MAYO CLINIC HEALTH SYSTEM AND MAYO CLINIC PARTNER TO ENSURE HEALTHIER LIVES IN THE REGION.IN 2012, MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) HAD 209 MEDICAL/SURGICAL ADMISSIONS AND 120 SWING BED ADMISSIONS WITH AN AVERAGE DAILY CENSUS OF 6.9. THERE WERE ALSO 2,351 EMERGENCY ROOM VISITS AND 195 OUTPATIENT SURGERIES. MCHS-CF PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER THEIR CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. SERVICES ARE ALSO PROVIDED TO BOTH MEDICAID AND MEDICARE PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. IN ADDITION, SERVICES ARE PROVIDED TO PATIENTS UNDER OTHER MEANS-TESTED GOVERNMENT PROGRAMS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. IN 2012, MCHS-CF PROVIDED APPROXIMATELY $88,300 IN CHARITY CARE TO PATIENTS. THE UNCOMPENSATED COST OF MEDICAID PATIENTS WAS APPROXIMATELY $202,100; AND THE COST OF PATIENTS UNDER OTHER MEANS TESTED GOVERNMENT PROGRAMS WAS APPROXIMATELY $80,800. 33682 9624 15027 COMMUNITY OUTREACH - SEE SCHEDULE OMAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) PARTICIPATES IN COMMUNITY AND SENIOR WELLNESS EVENTS WHERE FREE OR NOMINAL FEE SCREENING TESTS ARE OFFERED AS WELL AS FREE PATIENT EDUCATION MATERIALS. NO-COST FLU SHOT CLINICS ARE PROVIDED ANNUALLY AT THE SENIOR HEALTH FAIR. FREE COMMUNITY SCREENING FOR DIABETES IS DONE THROUGH A PARTNERSHIP WITH THE LOCAL LIONS CLUB AT THE MEDICAL CENTER ON AN ANNUAL BASIS. MCHS-CF MEALS ON WHEELS PROGRAM PROVIDES FREE HOME DELIVERED NOON MEALS TO HOMEBOUND SENIORS OVER 60 WITH A MODERATE TO HIGH NUTRITIONAL RISK. THIS PROGRAM IS AVAILABLE ON AN ANNUAL BASIS, MONDAY THROUGH FRIDAY TO APPROXIMATELY 16-22 PARTICIPANTS. MCHS-CF AUXILIARY PROVIDES APPROXIMATELY 20 VOLUNTEERS TO GREET AND DIRECT PATIENTS DURING HIGH-VOLUME SURGERY WEEKDAYS AND OFFER CLERICAL SUPPORT TO STAFF. THE AUXILIARY VOLUNTEERS PROVIDED APPROXIMATELY 621 HOURS OF VOLUNTEER SERVICES. BASED ON THE 2012 INDEPENDENT SECTOR STATISTICS, THE APPROXIMATE VALUE OF THESE SERVICES IS $13,750. THE AUXILIARY ALSO SPONSORS A SCHOLARSHIP PROGRAM FOR LOCAL STUDENTS PURSUING A CAREER IN A HEALTH-CARE RELATED FIELD, IN 2012 $1,500 WAS GIVEN OUT IN SCHOLARSHIPS. 100200 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) LEASES SPACE AND PROVIDES SUPPORT SERVICES TO AFFILIATED ORGANIZATIONS TO HELP FURTHER THEIR EXEMPT PURPOSE. 100200 17308910 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 0 0 237 1 0 0 0 0 0 0 0 0 0 0 X 9 4 1 1 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 1 0 MN X MAYO CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 ALTRICHTER MD PAUL M 1.00 40.00 X X 0 223050 51748 BAILEY TED 1.00 0.00 X 0 0 0 BERNARD MD MATTHEW E 1.00 40.00 X 0 257663 47428 BREKKEN KATHLEEN A 1.00 0.00 X 0 0 0 BRIGGS KATHLEEN E 1.00 0.00 X 0 0 0 PARKS DOUGLAS A 1.00 40.00 X X 0 189781 44522 WHITED MD BRIAN L 1.00 40.00 X 0 351898 38626 WITT MD THOMAS J 1.00 40.00 X X 0 452522 63616 WULF GREG 1.00 0.00 X 0 0 0 AGERTER MD DAVID C 1.00 40.00 X 0 483600 35091 CHRISTIAN GLENN P 40.00 1.00 X 176420 0 36914 KOCH MARK B 1.00 40.00 X 0 289086 16795 PILOT DAVID L 1.00 40.00 X 0 196045 33934 PRIEST WILLIAM F 40.00 0.00 X 196211 0 44846 TUSA EDWARD A 40.00 0.00 X 143951 0 43038 NORDAHL MD THOMAS W 40.00 0.00 X 398610 0 64622 TURNA MD TARLOCHAN S 40.00 0.00 X 442682 0 37382 CHESTNUT MD JANET S 40.00 0.00 X 312693 0 65909 DALEY MD JOHN R 40.00 0.00 X 121079 0 0 JOHNSTON-FLANDERS MD MEGAN S 40.00 0.00 X 210277 0 32671 STRICKER MD ALEXANDER W 40.00 0.00 X 209780 0 10284 WOLTER KIMBERLY D 40.00 0.00 X 127489 0 18155 ANGSTMAN MD GREGORY L 0.00 40.00 X 0 269734 34690 BIREN DAVID H 0.00 40.00 X 0 168420 17200 KRAMER CHERYL A 0.00 40.00 X 0 160314 8285 LOHR MD ROBERT H 0.00 40.00 X 0 238917 62645 TRANKEL SUSAN K 0.00 40.00 X 0 169339 15597 KRAWCZYK MD NICOLAS W 0.00 40.00 X 0 189570 6516 SUCHOMEL-OLSON MD ALICE M 0.00 40.00 X 0 150879 27112 2339192 3790818 857626 13 1 1 0 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 MEDICAL & ADMIN SERVICES 877009 MAYO CLINIC HEALTH SYSTEM-RED WING 1407 W 4TH STREET RED WING MN 55066 ADMIN SERVICES 399269 TW WALTER ANESTHESIA SERVICES INC 17189 COUNTY 27 BLVD PINE ISLAND MN 55963 ANESTHESIA (CRNA) 273257 GRAPETREE MEDICAL STAFFING INC 703 16TH STREET SPIRIT LAKE IA 51360 AHS STAFFING 181370 MAYO CLINIC HEALTH SYSTEM-LAKE CITY 500 WEST GRANT ST LAKE CITY MN 55041 ADMIN SERVICES 163363 8 7 3645 916393 145448 5480 1070973 NET PATIENT REVENUE 620000 16812249 16812249 LAB REVENUE 621510 5163887 5163887 RENTAL REVENUE FROM AFFILIATES 531120 95274 95274 MEALS ON WHEELS REVENUE 624210 15027 15027 22086437 24301 24301 21214 21214 0 1235 65595 -64360 -64360 -64360 5210 3645 1072 4138 4138 CAFETERIA/VENDING REVENUE 722210 39256 39256 MEDICAL RECORD/TRANSCRIPTION FEES 541900 8523 8523 MISCELLANOUS REVENUE 900099 4926 4926 1562 1562 54267 23175756 22139142 0 -34359 X 8100 8100 1524 1524 1584676 943296 641380 71018 71018 8466753 7670576 796177 474866 397221 77645 1297732 1085541 212191 619140 517905 101235 11240 11240 65000 65000 3463997 2307186 1156811 30614 30614 994813 889625 105188 263244 263244 174572 173591 981 6803 5501 1302 164239 137921 26318 7477 7477 531533 531533 36287 17422 18865 MEDICAL SUPPLIES 1318364 1318364 BAD DEBT EXPENSE 725491 725491 MN CARE TAX 200089 200089 MEDICAID SURCHARGE 140118 140118 198977 128798 70179 20856667 17308910 3482756 65000 751 953 951609 302567 379594 1608596 3321897 4587603 225070 201436 276047 213321 8533358 4361619 3819995 4171739 6861884 7576345 125400 600 15962247 18663160 1797879 1391356 296168 241097 2094047 1632453 X 10644638 12434744 3170982 4543383 52580 52580 13868200 17030707 15962247 18663160 X 2319089 4033 839385 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1106 1106 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE AMOUNT IN "OTHER ACTIVITIES" REPRESENTS A PORTION OF PROFESSIONAL DUES ATTRIBUTABLE TO LOBBYING. 52580 1066 1066 52580 52580 52580 52580 52580 52580 52580 52580 52580 1.00000 0 1 1 907081 907081 3616045 2228193 1387852 3434269 2133426 1300843 575963 575963 4171739 HOSPITAL DISTRICT INVESTMENT 2037828 F MAYO POOLED INVESTMENTS 5538517 F 7576345 ASSET RETIREMENT OBLIGATION 158373 DUE TO AFFILIATES 82724 241097 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS PROVIDE A STABLE FUNDING SOURCE TO SUPPORT THE MISSION OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: AT DECEMBER 31, 2012 AND 2011, UNRECOGNIZED TAX BENEFITS WAS NOT SIGNIFICANT, AND AS A RESULT, THERE IS NO LONGER A RESERVE FOR UNRECOGNIZED TAX BENEFITS RECORDED FOR THE FILING ORGANIZATION. X 1 DEAN J LINDEMAN 30596 OXFORD MILL RD CANNON FALLS MN 55009 FUNDRAISING 0 0 0 0 1 1 X 1 X 1 X 1 1 0 1 1 88299 88299 0.00440 1693156 1491089 202067 0.01000 114793 33999 80794 0.00400 1896248 1525088 371160 0.01840 40707 20615 20092 0.00100 1500 1500 0.00010 4158559 2127782 2030777 0.10090 4200766 2148397 2052369 0.10200 6097014 3673485 2423529 0.12040 950 950 0.00000 6450 6450 0.00030 7400 7400 0.00030 0 725491 5533687 5475206 58481 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS

1116 WEST MILL STREET CANNON FALLS MN 55009

X X X X HOSPITAL MAYO CLINIC HEALTH SYSTEM-CANNON FALLS 1 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X 1 0 X X X X X 1 X 0 0 1 MAYO CLINIC HEALTH SYSTEM-CANNON FALLS

1116 WEST MILL STREET CANNON FALLS MN 55009

CLINIC, SWING BED, DME PART I, LINE 6A: THE ANNUAL REPORT FOR THE FILING ORGANIZATION IS PART OF A CONSOLIDATED REPORT PREPARED BY MAYO CLINIC. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A-7C (FINANCIAL ASSISTANCE, MEDICAID SHORTFALL, AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS).THE AMOUNTS FOR LINES 7E-7I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND WOULD NOT BE BASED ON A COST-TO-CHARGE RATIO. 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 $ 725491. PART II: THE COMMUNITY BUILDING EXPENSES IN 2012 RELATE TO FUNDS PROVIDED TO THE CANNON FALLS EDUCATION FOUNDATION, THE CANNON FALLS LIBRARY FOUNDATION, CANNON FALLS COMMUNITY CHURCH AND SEVERAL SMALLER CHARITIES. THESE EXPENDITURES PROMOTED EDUCATION, SPIRITUAL GROWTH AND YOUTH ACTIVITIES. PART III, LINE 4: METHODOLOGY FOR SCHEDULE H, PART III, LINE 2:BAD DEBT EXPENSE IS DETERMINED BASED ON GAAP AND IS EXPLAINED IN THE ACCOUNTS RECEIVABLE FOOTNOTE OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS.FOOTNOTES RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS CAN BE FOUND ON PAGES 6, 8 AND 9 OF MAYO CLINIC'S 2012 CONSOLIDATED AUDITED FINANCIAL STATEMENTS.THE FILING ORGANIZATION REPORTS BAD DEBT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15 IS FOLLOWED TO THE EXTENT THAT IT ALIGNS WITH THE GUIDELINES SET FORTH BY GAAP. PART III, LINE 8: THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SURPLUS REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT (USING A MEDICARE COST REPORT STEP-DOWN METHODOLOGY). HOWEVER, USING A FINANCIAL STATEMENT COST-TO-CHARGE RATIO METHODOLOGY ACTUALLY RESULTS IN A MEDICARE SHORTFALL OF $282,357 AS REPORTED IN THE CORE FORM, PART III, PROGRAM SERVICE ACCOMPLISHMENTS.THE MOST COMMON REASONS FOR A DIFFERENCE BETWEEN THE MEDICARE SURPLUS REPORTED ON SCHEDULE H AND THE MEDICARE SHORTFALL REPORTED ON THE CORE FORM, PART III INCLUDE: (1) INCLUSION OF MEDICARE ADVANTAGE REVENUE AND EXPENSES; (2) INCLUSION OF PART B REVENUE AND EXPENSES; (3) INCLUSION OF OTHER FEE SCHEDULE REVENUE; AND (4) SOME TIMING ISSUES.REASONS WHY MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT ARE: (1) ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; (2) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; (3) THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS; AND (4) THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: MAYO CLINIC AND ITS AFFILIATES STRIVE TO ASSIST ALL PATIENTS IN MEETING THEIR FINANCIAL OBLIGATION PRIOR TO ENLISTING THE ASSISTANCE OF A COLLECTION AGENCY BY MAKING REASONABLE ATTEMPTS TO COLLECT FROM INSURANCE COMPANIES AND OTHER THIRD-PARTY PAYORS. IN ADDITION, MAYO CLINIC AND ITS AFFILIATES ACCEPT REASONABLE PAYMENT PLANS FROM PATIENTS WHEN AN ACCOUNT IS THE PATIENT'S RESPONSIBILITY AND TRY TO IDENTIFY THOSE PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. FINANCIAL ASSISTANCE IS OFFERED TO ANY PATIENT IF THE FACTS AND CIRCUMSTANCES SUGGEST THAT THE PATIENT DOES NOT HAVE THE ABILITY TO PAY THEIR BILL IN WHOLE OR IN PART. IN THE EVENT THAT AN ACCOUNT IS REFERRED TO A COLLECTION AGENCY, GUIDELINES ARE FOLLOWED; INCLUDING SUSPENDING ALL COLLECTION ACTIVITY IF A FINANCIAL ASSISTANCE APPLICATION HAS BEEN SUBMITTED AFTER THE ACCOUNT HAS BEEN REFERRED FOR COLLECTION. IF A COLLECTION AGENCY IDENTIFIES A PATIENT AS MEETING MAYO CLINICS FINANCIAL ASSISTANCE ELIGIBILTY CRITERIA OR THE PATIENT ASKS TO APPLY FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY IS SUSPENDED UNTIL MAYO REVIEWS THE ACCOUNT FOR FINANCIAL ASSISTANCE ELIGIBILITY BASED ON SUBMISSION OF REQUESTED INFORMATION. COLLECTION ACTIVITY WOULD ONLY RESUME IF MAYO WOULD TELL THE COLLECTION AGENCY TO PURSUE COLLECTIONS ON THE BALANCE OR PARTIAL BALANCE IF THERE WAS A CHARITY ADJUSTMENT. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS PART V, SECTION B, LINE 14G: WITH REGARD TO THE POSTINGS WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS PART V, SECTION B, LINE 18E: FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE TO EVERY PATIENT VIA MAYO'S PUBLIC WEBSITE, FROM CUSTOMER SERVICE AND PATIENT ACCESS LOCATIONS, AND IS REFERENCED ON MAYO'S AUTHORIZATION FORMS AND STATEMENTS. IN ADDITION, BROCHURES ARE AVAILABLE IN THE ADMISSIONS AREA AND THE PROCESS OF HOW TO APPLY IS AVAILABLE ON THE MAYO CLINIC WEBSITE.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, MAYO DISCUSSES ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE.MONTHLY STATEMENTS ARE SENT TO PATIENTS THAT OUTLINE CURRENT CHARGES AND ACTIONS WITH INSURANCE AND INCLUDES INFORMATION ABOUT MAYO'S CHARITY CARE POLICY. SOME MAYO SITES UTILIZE ADVOCATES TO CONTACT THE PATIENT UPON DISCHARGE TO HELP THEM SECURE GOVENMENTAL ASSISTANCE OR FINANCIAL ASSISTANCE.EACH CHARITY CARE REVIEW IS DOCUMENTED IN MAYO'S BILLING SYSTEM AND COMMUNICATED TO THE PATIENT. COMPLETED CHARITY CARE FORMS ARE MAINTAINED EITHER IN PAPER OR ELECTRONIC FORMAT. THE PATIENT IS INFORMED REGARDING THE OUTCOME OF THE REVIEW.MAYO OFTEN IDENTIFIES CHARITY CARE OPPORTUNITIES AFTER THE PATIENT HAS BEEN DISMISSED. IN MANY CASES, THIS IS DUE TO LIMITED INSURANCE COVERAGE OR INSURANCE DENIALS AFTER THE SERVICE WAS PERFORMED. IN THESE CASES, WHEN A PATIENT EXPRESSES AN INABILITY TO PAY FOR THEIR SERVICES, STAFF WILL INITIATE A CHARITY REVIEW AS INDICATED BY THE FINANCIAL ASSISTANCE POLICY, WHICH IS AVAILABLE FOR EVERY PATIENT AT MAYOCLINIC.ORG. MAYO CLINIC HEALTH SYSTEM-CANNON FALLS PART V, SECTION B, LINE 20D: OUR POLICY ALLOWS FOR A MINIMUM DISCOUNT OF 50% TO ELIGIBLE INDIVIDUALS WHICH RESULTS IN AN AMOUNT LESS THAN THE AVERAGE OF THE THREE BEST NEGOGIATED COMMERCIAL RATES OR THE BEST NEGOGIATED COMMERCIAL RATE. PART VI, LINE 2: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) DETERMINES PATIENT NEEDS THROUGH A VARIETY OF MEANS: DIRECT FEEDBACK FROM PATIENTS TO EMPLOYEES AT POINT OF CARE AND AT OTHER OPPORTUNITIES, THROUGH COMMUNITY REPRESENTATION ON THE MEDICAL CENTER COMMUNITY ADVISORY COUNCIL AND THROUGH CONTINUAL, RANDOM, CONFIDENTIAL PATIENT SATISFACTION SURVEYS WHICH ARE PART OF THE DECISION-MAKING PROCESSES FOR IMPROVING PATIENT CARE AND CUSTOMER SERVICE. PART VI, LINE 3: MEASURES TO PUBLICIZE FINANCIAL ASSISTANCE POLICY:MAYO CLINIC IS COMMITTED TO OFFERING FINANCIAL ASSISTANCE TO ELIGIBLE PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY FOR THEIR MEDICAL SERVICES IN WHOLE OR IN PART. IN ORDER TO ACCOMPLISH THIS CHARITABLE GOAL, MAYO CLINIC AND MAYO CLINIC HEALTH SYSTEM SITES WIDELY PUBLICIZE THIS POLICY IN THE COMMUNITIES THAT THE INDIVIDUAL MAYO CLINIC AFFILIATED SITES SERVE. MAYO CLINIC AFFILIATED SITES MAKE COPIES OF THIS POLICY AVAILABLE BY POSTING IT ON THEIR WEBPAGE INCLUDING THE ABILITY TO DOWNLOAD A COPY OF THE POLICY FREE OF CHARGE. INDIVIDUALS IN THE COMMUNITY SERVED WILL BE ABLE TO OBTAIN A COPY OF THE POLICY IN LOCATIONS THROUGHOUT EACH MAYO CLINIC AFFILIATED SITE OR UPON REQUEST. THE POLICY EXPLAINS THE FINANCIAL ASSISTANCE PROGRAM AND FACTORS AFFECTING ELIGIBILITY. WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED. PART VI, LINE 4: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS (MCHS-CF) IS LOCATED IN CANNON FALLS, MINNESOTA. MCHS-CF SERVES CANNON FALLS AND THE SURROUNDING AREA WITHIN GOODHUE COUNTY. CANNON FALLS IS A RURAL COMMUNITY WITH A POPULATION OF 4,086 AS OF JULY 2011. THE SERVICE AREA POPULATION WAS 12,789 AS OF JULY 2011. THE POPULATION IS 48.3% MALE AND 51.7% IS FEMALE. THE MEDIAN RESIDENT AGE IS 40.0 YEARS OF AGE. THE ESTIMATED MEDIAN HOUSEHOLD INCOME IN CANNON FALLS FOR 2010 WAS $40,721. ACCORDING TO 2010 DATA, 5.6% OF RESIDENTS HAVE AN INCOME BELOW THE POVERTY LEVEL, WHILE 3.5% OF RESIDENTS HAVE AN INCOME BELOW 50% OF THE POVERTY LEVEL. PART VI, LINE 5: THIS FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES ARE LARGE, MULTI-FACETED, INTEGRATED, NOT-FOR-PROFIT GROUP PRACTICES AND HEALTH SYSTEMS. AT MAYO CLINIC, DOCTORS FROM EVERY MEDICAL SPECIALTY WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF "THE NEEDS OF THE PATIENT COME FIRST." THE ORGANIZATIONS (INCLUDING HOSPITAL AND NON-HOSPITAL ENTITIES) WORK TOGETHER TO SERVE THEIR COMMUNITIES AT THE LOCAL, REGIONAL, NATIONAL, AND GLOBAL LEVELS. THIS COMMUNITY BENEFIT HAPPENS THROUGH ITS FOCUS ON PATIENT CARE, EDUCATION, AND RESEARCH. SPECIFICALLY, THE TAX-EXEMPT PURPOSE OF MAYO CLINIC AND ITS AFFILIATES IS THREE-FOLD:PRACTICE - PRACTICE MEDICINE AS AN INTEGRATED TEAM OF COMPASSIONATE, MULTI-DISCIPLINARY PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS WHO ARE FOCUSED ON THE NEEDS OF PATIENTS FROM OUR COMMUNITIES, REGIONS, THE NATION AND THE WORLD.EDUCATION - EDUCATE PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS AND BE A DEPENDABLE SOURCE OF HEALTH INFORMATION FOR OUR PATIENTS AND THE PUBLIC.RESEARCH - CONDUCT BASIC AND CLINICAL RESEARCH PROGRAMS TO IMPROVE PATIENT CARE AND TO BENEFIT SOCIETY, INCLUDING PARTNERING WITH MAYO CLINIC HEALTH SYSTEM PRACTICES TO PERFORM PRACTICE-BASED RESEARCH DESIGNED TO IMPROVE PATIENT CARE.THROUGH ITS MISSION, MAYO CLINIC AND ITS AFFILIATES ENRICH THE COMMUNITIES IN WHICH THEY OPERATE AS WELL AS THE BROADER COMMUNITY - IMPROVING MEDICINE THROUGH RESEARCH, EDUCATING PHYSICIANS AND OTHER HEALTH CARE PROVIDERS, AND PROVIDING CARE AND SUPPORT TO PEOPLE IN NEED. PLEASE REFER TO THE PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, FOR FURTHER DESCRIPTION OF THE FILING ORGANIZATIONS ACTIVITIES.SURPLUS FUNDSMAYO CLINIC AND ITS AFFILIATES REINVEST THEIR NET OPERATING INCOME TO ADVANCE MEDICAL RESEARCH AND TEACH THE NEXT GENERATION OF HEALTH CARE PROFESSIONALS, AS WELL AS TO ALLOW THE INDIVIDUAL ENTITY TO SUSTAIN ITS MISSION AND PREPARE FOR THE FUTURE. COMMUNITY REPRESENTATION ON GOVERNING BODYTHE BOARD OF TRUSTEES IS THE GOVERNING BODY OF MAYO CLINIC. A MAJORITY OF ITS MEMBERS ARE EXTERNAL, INDEPENDENT TRUSTEES. IT HAS OVERALL RESPONSIBILITY FOR THE CHARITABLE, CLINICAL PRACTICE, SCIENTIFIC AND EDUCATIONAL MISSION AND PURPOSES OF MAYO CLINIC AND ITS AFFILIATES AS SET FORTH IN ITS ARTICLES OF INCORPORATION AND BYLAWS. BECAUSE OF MAYO CLINICS NATIONAL PRESENCE, THESE TRUSTEES ARE SELECTED BASED ON THEIR AREAS OF EXPERTISE, WHETHER IN HEALTH CARE POLICY, BUSINESS, GOVERNMENT OR ANOTHER FIELD. IN ADDITION TO THIS COMMUNITY REPRESENTATION AT THE PARENT ENTITY, THE FILING ORGANIZATION ALSO INVOLVES LOCAL COMMUNITY MEMBERS ON ITS GOVERNING BODY. OPEN V. CLOSED STAFF MODEL STAFF PRIVILEGES ARE GENERALLY EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY.EMERGENCY ROOM THE FILING ORGANIZATION MAINTAINS AN EMERGENCY ROOM 24 HOURS A DAY, 7 DAYS A WEEK, WHICH IS OPEN TO ALL WITHOUT REGARD TO THE ABILITY TO PAY PART VI, LINE 6: THIS ORGANIZATION IS A PART OF MAYO CLINIC HEALTH SYSTEM (WHICH IS PART OF A LARGER GROUP OF ENTITIES AFFILIATED WITH MAYO CLINIC). THE MAYO CLINIC HEALTH SYSTEM IS DESCRIBED IN RESPONSE TO CORE FORM, PART III, STATEMENT OF PROGRAM ACCOMPLISHMENTS, LINE 4A (REPORTED IN SCHEDULE O). THAT STATEMENT ALSO DESCRIBES THE ROLES OF THE VARIOUS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED. PART VI, LINE 7 NEITHER THE FILING ORGANIZATION, NOR ANY RELATED ORGANIZATION, FILES A COMMUNITY BENEFIT REPORT WITH ANY STATE OTHER THAN THE EXTENT TO WHICH COMMUNITY BENEFIT INFORMATION IS INCLUDED IN OTHER REPORTING REQUIREMENTS SUCH AS INFORMATION PROVIDED ON THE MINNESOTA HOSPITAL ANNUAL REPORT OR TO THE WISCONSIN HOSPITAL ASSOCIATION. 1 CANNON FALLS LIBRARY FOUNDATION 306 MILL ST W CANNON FALLS MN 55009 411962864 501(C)(3) 5000 SUPPORT MISSION SUPPORT MISSION 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE FILING ORGANIZATION CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY WITH PROGRAMS THAT ENHANCE THE MISSION OF THE FILING ORGANIZATION. THE FILING ORGANIZATION ONLY CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY THAT ADDRESS UNMET OR UNDER-FUNDED COMMUNITY NEEDS IN THE AREAS OF HEALTHCARE, EDUCATION, RESEARCH, DIVERSITY AND EQUALITY OF OPPORTUNITY. SCHEDULE I, PART III, COLUMN (B) THE FILING ORGANIZATION ESTIMATED THE NUMBER OF RECIPIENTS FOR EACH TYPE OF GRANT OR ASSISTANCE BASED UPON THE ACTUAL BOOKS AND RECORDS OF THE ORGANIZATION. 0 1 0 0 0 0 0 0 0 ALTRICHTER MD PAUL M 0 222520 0 0 0 530 0 24511 0 27237 0 274798 0 0 BERNARD MD MATTHEW E 0 254728 0 0 0 2935 0 27258 0 20170 0 305091 0 0 PARKS DOUGLAS A 0 188612 0 0 0 1169 0 20335 0 24187 0 234303 0 0 WHITED MD BRIAN L 0 351898 0 0 0 0 0 12500 0 26126 0 390524 0 0 WITT MD THOMAS J 0 410870 0 0 0 41652 0 42967 0 20649 0 516138 0 0 AGERTER MD DAVID C 0 449783 0 0 0 33817 0 19707 0 15384 0 518691 0 0 CHRISTIAN GLENN P 176420 0 0 0 0 0 23244 0 13670 0 213334 0 0 0 KOCH MARK B 0 279804 0 0 0 9282 0 322 0 16473 0 305881 0 0 PILOT DAVID L 0 196045 0 0 0 0 0 13937 0 19997 0 229979 0 0 PRIEST WILLIAM F 196211 0 0 0 0 0 23036 0 21810 0 241057 0 0 0 TUSA EDWARD A 143951 0 0 0 0 0 16957 0 26081 0 186989 0 0 0 NORDAHL MD THOMAS W 398610 0 0 0 0 0 39040 0 25582 0 463232 0 0 0 TURNA MD TARLOCHAN S 442682 0 0 0 0 0 22947 0 14435 0 480064 0 0 0 CHESTNUT MD JANET S 312693 0 0 0 0 0 46944 0 18965 0 378602 0 0 0 JOHNSTON-FLANDERS MD MEGAN S 190277 0 20000 0 0 0 9335 0 23336 0 242948 0 0 0 STRICKER MD ALEXANDER W 209780 0 0 0 0 0 10284 0 0 0 220064 0 0 0 ANGSTMAN MD GREGORY L 0 263190 0 6544 0 0 0 19472 0 15218 0 304424 0 0 BIREN DAVID H 0 166322 0 0 0 2098 0 32 0 17168 0 185620 0 0 KRAMER CHERYL A 0 150408 0 0 0 9906 0 86 0 8199 0 168599 0 0 LOHR MD ROBERT H 0 236020 0 0 0 2897 0 41981 0 20664 0 301562 0 0 TRANKEL SUSAN K 0 166694 0 0 0 2645 0 25 0 15572 0 184936 0 0 KRAWCZYK MD NICOLAS W 0 163479 0 0 0 26091 0 0 0 6516 0 196086 0 0 SUCHOMEL-OLSON MD ALICE M 0 149029 0 0 0 1850 0 17665 0 9447 0 177991 0 0 PART I, LINE 4B THIS ENTITY OR ITS AFFILIATE HAS A SUPPLEMENTAL RETIREMENT PLAN (SRP) DESIGNED TO ROUGHLY APPROXIMATE AN EXTENSION OF THE BENEFITS UNDER THE MAYO PENSION PLAN TO INCOME ABOVE THE INTERNAL REVENUE CODE QUALIFIED PLAN LIMIT IN SECTION 401(A)(17). STARTING JANUARY 1, 2011, ALL SRP BENEFITS ARE PAID AS AN ANNUAL TAXABLE CASH PAYMENT. THE FOLLOWING INDIVIDUALS RECEIVED A PAYMENT FROM THE SUPPLEMENTAL RETIREMENT PLAN. AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III). A PORTION OF THE AMOUNT MAY BE INCLUDED IN SCHEDULE J, PART II, COLUMN (F) IF DISCLOSED ON A PRIOR YEAR'S FORM 990. DAVID C. AGERTER, M.D. $27,454 MATTHEW BERNARD, M.D. $1,852 MARK B. KOCH $8,013 THOMAS J. WITT M.D. $30,605 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: THE FILING ORGANIZATION RELIED ON A RELATED ORGANIZATION FOR ESTABLISHING THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. SEE CORE 990 PART VI SECTION B LINE 15 FOR FURTHER INFORMATION REGARDING THE PROCESS UTILIZED. COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. RYAN SCHRAMN SON-IN-LAW OF BOARD OFFICER, GLENN CHRISTIAN 71018 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUALS ARE EMPLOYED BY A RELATED ORGANIZATION: CIOTA M.D., MARK R. PILOT, DAVID L. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS WHO ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: AGERTER M.D., DAVID C. CIOTA M.D., MARK R. KOCH, MARK B. PARKS, DOUGLAS A. PILOT, DAVID L. THE FOLLOWING INDIVIDUAL IS EMPLOYED BY A RELATED ORGANIZATION: WITT M.D., THOMAS J. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS WHO ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: AGERTER M.D., DAVID C. CIOTA M.D., MARK R. KOCH, MARK B. PARKS, DOUGLAS A. PILOT, DAVID L. WITT M.D., THOMAS J. THE FOLLOWING INDIVIDUALS ARE EMPLOYED BY A RELATED ORGANIZATION: WHITED M.D., BRIAN L RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL WHO IS ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: KOCH, MARK B. FORM 990, PART VI, SECTION A, LINE 3 MAYO CLINIC, MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH, AND OTHER RELATED COMPANIES PROVIDE MANAGEMENT SERVICES TO THE ENTIRE SYSTEM OF ENTITIES. SINCE THE ENTITIES ARE RELATED ORGANIZATIONS, COMPENSATION FOR THE OFFICERS, DIRECTORS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES HAS BEEN DISCLOSED IN PART VII AND SCHEDULE J AS REQUIRED. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS MAYO CLINIC. FORM 990, PART VI, SECTION A, LINE 7A THE GOVERNING BODY OF THE FILING ORGANIZATION CONSISTS OF NINE PERSONS ELECTED AS FOLLOWS: (A) FOUR COMMUNITY TRUSTEES ELECTED BY THE CANNON FALLS HOSPITAL DISTRICT; (B) CHAIR/CEO AND VICE CHAIR ELECTED BY THE BOARD OF TRUSTEES AND APPROVED BY THE SOLE MEMBER; AND (C) THREE MEMBER TRUSTEES ELECTED BY THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B MAYO CLINIC, THE SOLE CORPORATE MEMBER OF THE FILING ORGANIZATION, MUST APPROVE THE PERSON ELECTED AS THE VICE CHAIR. THE FILING ORGANIZATION'S BYLAWS ALSO PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, AMENDMENT OF ARTICLES OR BYLAWS AND DEBT DECISIONS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY MAYO CORPORATE TAX WITH ASSISTANCE FROM SITE ACCOUNTING STAFF. THE TAX RETURN GOES THROUGH TWO LEVELS OF REVIEW WITHIN THE CORPORATE TAX UNIT. IT IS THEN REVIEWED BY THE CHIEF FINANCIAL OFFICER AND FINANCE STAFF. A COPY OF THE FORM 990 IS THEN PROVIDED TO EACH MEMBER OF THE FILING ORGANIZATION'S GOVERNING BODY VIA US MAIL, E-MAIL, OR DISTRIBUTION AT A BOARD MEETING. ALL QUESTIONS ARE ADDRESSED PRIOR TO FILING THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C MAYO CLINIC AND ITS AFFILIATES HAVE A COMPREHENSIVE CONFLICT OF INTEREST POLICY APPLICABLE TO ALL OF THE AFFILIATED ENTITIES AND TO ALL DIRECTORS, OFFICERS, AND EMPLOYEES OF THOSE ENTITIES. ALL CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES WHO WE ANTICIPATE WILL BE LISTED ON A FORM 990 ARE ASKED TO COMPLETE AN "ANNUAL TAX AND COMPLIANCE DISCLOSURE" FORM. THIS INFORMATION IS REVIEWED BY BOTH THE CORPORATE TAX DEPARTMENT AND THE OFFICE OF CONFLICT OF INTEREST REVIEW. ALL DISCLOSURES OF CURRENT OR PROPOSED ACTIVITY THAT REQUIRE ACTION UNDER THE POLICY ARE THE SUBJECT OF ONGOING REVIEW AND ACTION THROUGH THE OFFICE OF CONFLICT OF INTEREST REVIEW AND THE CONFLICT OF INTEREST REVIEW BOARD. INVOLVED INDIVIDUALS ARE INFORMED OF ALL REQUIRED ACTION. MANY TYPES OF RELATIONSHIPS THAT COULD CREATE CONFLICTS OF INTEREST ARE PROHIBITED. OTHER TYPES OF RELATIONSHIPS ARE PERMITTED SUBJECT TO COMPLIANCE WITH THE MANAGEMENT PLAN ESTABLISHED BY THE CONFLICT OF INTEREST REVIEW BOARD. A COMMON MANAGEMENT STRATEGY FOR PERMITTED ACTIVITIES IS TO REQUIRE BILATERAL RECUSAL AND APPROPRIATE DOCUMENTATION IN THE MINUTES OF MAYO CLINIC (AND/OR AFFILIATE) AND THE OUTSIDE ENTITY. ADDITIONAL CONFLICT OF INTEREST POLICIES AND PROCEDURES EXIST FOR CERTAIN ENTITIES CONCERNING RESEARCH CONTRACTS AND OTHER TYPES OF POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15B THE FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES HAVE A COORDINATED PROCESS FOR REVIEWING AND APPROVING COMPENSATION AND BENEFITS FOR PHYSICIANS AND ADMINISTRATIVE LEADERSHIP. IN ADDITION TO ANY REVIEW AND APPROVAL THAT MAY TAKE PLACE AT THE LOCAL ENTITY LEVEL, THE FOLLOWING INDEPENDENT APPROVAL PROCESS OCCURS ANNUALLY IN THE FALL FOR THE NEXT YEAR'S COMPENSATION. THE SALARY OF THE CEO (THOMAS WITT, M.D.) AND CAO (BILL PRIEST) WERE REVIEWED BY THE MAYO CLINIC HEALTH SYSTEM COMPENSATION AND BENEFITS COMMITTEE PURSUANT TO THE PROCESS DESCRIBED BELOW FOR MAYO CLINIC HEALTH SYSTEM PHYSICIAN AND ADMINISTRATIVE LEADERSHIP. THE MAYO CLINIC HEALTH SYSTEM COMPENSATION AND BENEFITS COMMITTEE INITIALLY REVIEWS THE COMPENSATION OF PHYSICIANS AND ADMINISTRATIVE LEADERSHIP FOR THE MAYO CLINIC HEALTH SYSTEM ENTITIES. THE COMMITTEE IS COMPRISED OF MAYO CLINIC EMPLOYEES, BUT IS INDEPENDENT FOR INTERNAL REVENUE CODE 4958 FOR THE INDIVIDUALS WHOSE SALARY IS REVIEWED (WITH RECUSAL WHERE APPROPRIATE). THE MAYO CLINIC SALARY AND BENEFITS COMMITTEE THEN REVIEWS AND APPROVES THE COMPENSATION. FOR THOSE INDIVIDUALS FOR WHICH THE MAYO CLINIC HEALTH SYSTEM COMMITTEE CAN NOT SERVE AS THE INDEPENDENT REVIEW, THEIR COMPENSATION AND BENEFITS ARE REVIEWED BY THE GOVERNANCE COMMITTEE (DESCRIBED BELOW). THE COMPENSATION AND BENEFITS COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. INFORMATION ON MAYO CLINIC HEALTH SYSTEM PHYSICIAN AND ADMINISTRATIVE LEADERSHIP COMPENSATION AND BENEFITS IS ALSO REVIEWED BY THE MAYO CLINIC COMMITTEE ON OFFICER SUCCESSION, COMPENSATION AND GOVERNANCE (GOVERNANCE COMMITTEE), WHICH IS COMPRISED OF SEVEN OF THE EXTERNAL INDEPENDENT MEMBERS OF THE MAYO CLINIC BOARD OF TRUSTEES. IN ADDITION TO THE ABOVE COORDINATED REVIEW PROCESS CONDUCTED AT MAYO CLINIC AND ITS AFFILIATES, THE FILING ORGANIZATION ALSO HAS ITS OWN COMPENSATION REVIEW PROCESS FOR THE CEO AND OTHER TOP MANAGEMENT OFFICIALS. THE PROCESS INCLUDES REVIEW OF COMPARABILITY DATA FOR SIMILAR SIZED ORGANIZATIONS BY AN INDEPENDENT COMMITTEE OF THE BOARD (PUBLIC MEMBERS ONLY). SALARY RANGES FOR THE PAST YEAR AND RANGES FOR THE NEXT YEAR ARE REVIEWED FOR REASONABLENESS. CONTEMPORANEOUS MEETING MINUTES OF THE COMPENSATION COMMITTEE ARE KEPT ON FILE. FORM 990, PART VI, SECTION C, LINE 19 THE FILING ORGANIZATION'S GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST AND ALSO ON THE MAYOCLINIC.ORG WEBSITE. THE FILING ORGANIZATION IS A HOSPITAL AFFILIATED WITH MAYO CLINIC. AS SUCH, MAYO CLINIC'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO THE FILING ORGANIZATION'S FORM 990 AND WOULD BE AVAILABLE UPON REQUEST OF THE FORM 990. OTHER FEES FORM 990, PART IX, LINE 11G PHYSICIAN SERVICES : PROGRAM SERVICE EXPENSES 895,770. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 895,770. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 320,279. MANAGEMENT AND GENERAL EXPENSES 102,075. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 422,354. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 309,952. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 309,952. LAB SERVICES: PROGRAM SERVICE EXPENSES 199,800. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 199,800. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 222,919. MANAGEMENT AND GENERAL EXPENSES 522,061. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 744,980. SHARED SERVICES W/ AFFILIATES: PROGRAM SERVICE EXPENSES 317,078. MANAGEMENT AND GENERAL EXPENSES 502,589. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 819,667. OTHER FEES: PROGRAM SERVICE EXPENSES 41,388. MANAGEMENT AND GENERAL EXPENSES 30,086. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 71,474. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: PLEDGE RECEIVABLE ADJUSTMENT 839,385. IN REGARDS TO FILING CERTAIN FOREIGN FORMS SCHEDULE F, PART IV, LINES 3,5,& 6 DISCLOSURE STATEMENT RELATED TO FORMS 5713: FORM 5713 HAS BEEN FILED BY THE FOLLOWING MEMBERS OF THE CONTROLLED GROUP: MAYO CLINIC (EIN: 41-6011702) MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH (EIN: 41-1506440) BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(C)(3) 7 MCHS--CHIPPEWA VALLEY INC 1 CHARTERHOUSE INC 200 FIRST STREET SW ROCHESTER MN 55905 411405254 RETIREMENT LIVING CENTER MN 501(C)(3) 9 MAYO CLINIC 1 FRANCISCAN SKEMP FOUNDATION OF ARCADIA INC 464 SOUTH ST JOSEPH AVENUE ARCADIA WI 54612 391322480 FUNDRAISING FOUNDATION WI 501(C)(3) 9 MCHS--FRANCISCAN HEALTHCARE INC 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(C)(3) 9 MFMER 1 LUTHER LAKESIDE APARTMENTS INC PO BOX 1510 EAU CLAIRE WI 54702 391409024 LOW INCOME HOUSING FOR ELDERLY WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - CLINIC MN 501(C)(3) 9 N/A 1 MAYO CLINIC -- METHODIST HOSPITAL 200 FIRST STREET SW ROCHESTER MN 55905 410739106 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC -- SAINT MARYS HOSPITAL 200 FIRST STREET SW ROCHESTER MN 55905 410944601 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC ARIZONA 13400 EAST SHEA BOULEVARD SCOTTSDALE AZ 85259 860800150 HOSPITAL AND CLINIC AZ 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC FLORIDA (A NONPROFIT CORPORATION) 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 590714831 HOSPITAL FL 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS INC 1900 TEBEAU STREET WAYCROSS GA 31501 581667166 HOSPITAL GA 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MAYO CLINIC HEALTH SYSTEM--ALBERT LEA 1000 FIRST DRIVE NW AUSTIN MN 55912 411404075 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--AUSTIN 1000 FIRST DRIVE NW AUSTIN MN 55912 410695606 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--AUSTIN FOUNDATION 1000 FIRST DRIVE NW AUSTIN MN 55912 300107471 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--AUSTIN 1 MAYO CLINIC HEALTH SYSTEM--CANNON FALLS 1116 WEST MILL STREET CANNON FALLS MN 55009 204156428 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--CHIPPEWA VALLEY INC 1501 THOMPSON STREET BLOOMER WI 54724 390980343 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE CLINIC INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391735831 PATIENT CARE - CLINIC WI 501(C)(3) 3 MAYO CLINIC 0 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE FOUNDATION INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391633407 GRANTMAKING FOUNDATION WI 501(C)(3) 11-I MCHS--EAU CLAIRE CLINIC INC 0 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE HOSPITAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 390813418 HOSPITAL WI 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--FAIRMONT 800 MEDICAL CENTER DRIVE PO BOX 800 FAIRMONT MN 56031 410760836 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN HEALTHCARE FOUNDATION INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391186647 FUNDRAISING FOUNDATION WI 501(C)(3) 7 MCHS--FRANCISCAN HEALTHCARE INC 1 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN HEALTHCARE FOUNDATION-SPARTA INC 310 WEST MAIN STREET SPARTA WI 54656 391423234 FUNDRAISING FOUNDATION WI 501(C)(3) 9 MCHS--FRANCISCAN HEALTHCARE INC 1 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN HEALTHCARE INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391411999 HEALTHCARE SYSTEM PARENT WI 501(C)(3) 11-I MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN MEDICAL CENTER INC 700 WEST AVE SOUTH LA CROSSE WI 54601 390806374 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--FRANCISCAN HEALTHCARE INC 1 MAYO CLINIC HEALTH SYSTEM--HOME HEALTH & HOSPICE INC PO BOX 2060 EAU CLAIRE WI 54702 391491516 HOME HEALTH AND HOSPICE CARE WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--LAKE CITY 500 WEST GRANT STREET LAKE CITY MN 55041 411906820 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--MANKATO 1025 MARSH STREET MANKATO MN 56002 411236756 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--MANKATO HEALTH CARE FOUNDATION 1025 MARSH STREET MANKATO MN 56002 411663357 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--NEW PRAGUE 301 SECOND STREET NE NEW PRAGUE MN 56071 410723639 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--NORTHLAND INC 1222 EAST WOODLAND AVENUE BARRON WI 54812 390920634 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--OAKRIDGE INC 13025 EIGHTH STREET PO BOX 70 OSSEO WI 54758 391029430 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--OWATONNA 134 SOUTHVIEW ST OWATONNA MN 55060 411862132 PATIENT CARE - CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--RED CEDAR INC 2321 STOUT ROAD MENOMONIE WI 54751 510190875 HOSPITAL AND CLINIC WI 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--RED WING 701 HEWITT BOULEVARD RED WING MN 55066 411713783 PATIENT CARE SERVICES MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--RED WING HOME HEALTH & HOSPICE 701 HEWITT BOULEVARD RED WING MN 55066 411539756 HOME HEALTHCARE SERVICES MN 501(C)(3) 7 MCHS--RED WING 1 MAYO CLINIC HEALTH SYSTEM--SPRINGFIELD 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--ST JAMES 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 410797368 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--ST JAMES HEALTH CARE FOUNDATION 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 411444129 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--ST JAMES 1 MAYO CLINIC HEALTH SYSTEM--SUPPORTIVE HOMECARE INC PO BOX 2060 EAU CLAIRE WI 54702 391686673 HOME HEALTH CARE WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--WASECA 501 NORTH STATE STREET WASECA MN 56093 363606405 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MAYO CLINIC JACKSONVILLE 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 593337028 PATIENT CARE - CLINIC FL 501(C)(3) 7 MAYO CLINIC 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 200 FIRST STREET SW ROCHESTER MN 55905 411506440 CHARITABLE, EDUCATIONAL & SCIENTIFIC ACTIVITIES MN 501(C)(3) 9 MAYO CLINIC 1 MAYO KLINIK STIFTUNG 60486 FRANKFURT AM MAIN FRANKFURT GM FUNDRAISING FOUNDATION GM MFMER 1 MILES AND SHIRLEY FITERMAN ENDOWMENT FUND FOR DIGESTIVE DISEASES 200 FIRST STREET SW ROCHESTER MN 55905 412020392 SUPPORT RESEARCH, PRACTICE & EDUCATION MN 501(C)(3) 11-I MAYO CLINIC 1 POVERELLO FOUNDATION 200 FIRST STREET SW ROCHESTER MN 55905 411494881 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MAYO CLINIC -- SAINT MARYS HOSPITAL 1 RED WING SEMINARY HOME 701 HEWITT BOULEVARD RED WING MN 55066 411263419 RESIDENT CARE AND HOUSING MN 501(C)(3) 9 MCHS--RED WING 1 SATILLA HEALTH MANAGEMENT INC 1900 TEBEAU STREET WAYCROSS GA 31501 581717889 HEALTHCARE SERVICES GA 501(C)(3) 3 MCHS IN WAYCROSS INC 1 THE DOWNTOWN PLAZA 701 HEWITT BOULEVARD RED WING MN 55066 411532554 ELDERLY HOUSING MN 501(C)(3) 9 MCHS--RED WING 1 FRANKLIN HEATING STATION 119 THIRD ST SW ROCHESTER MN 55902 410264830 UTILITY MN N/A PHYSICIAN SOFTWARE SYSTEMS LLC 3333 WARRENVILLE ROAD SUITE 200 LISLE IL 60532 453414836 HEALTHCARE RELATED SOFTWARE IL N/A HEALTH TRADITION HEALTH PLAN 1808 EAST MAIN STREET ONALASKA WI 54650 391545987 MEDICAL SERVICES COMPANY WI N/A C 1 LOBSS NETWORK SUPPORT 2002 INC 200 FIRST STREET SW ROCHESTER MN 55905 481276150 ADMINISTRATIVE SERVICES MN N/A C 1 MAYO CLINIC GBS MAURITIUS 2ND FLOOR EBENE MEWS 57 EBENE CYBERCITY MP HEALTHCARE MANAGEMENT MP N/A C 1 MAYO CLINIC HEALTH SYSTEM--DECORAH CLINIC PHYSICIANS 907 MONTGOMERY STREET DECORAH IA 52101 411711329 PATIENT CARE - 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