2013-11-08T10:13:10-06:00 2012-12-31 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST STE 2300 MINNEAPOLIS MN 55402 990 2012-01-01 410729979 NORTH MEMORIAL HEALTH CARE NORT 7635205200 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 TODD OSTENDORF 7635205200 2013-11-06 1 LAWRENCE H MOHR CPA P00447603 6128764500 2012 2016-02-25 16:41:14Z LOREN TAYLOR 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 721988510 0 X WWW.NORTHMEMORIAL.COM X 1954 MN GENERAL ACUTE CARE HOSPITAL PROVIDING HIGHLY SPECIALIZED TRAUMA AND EMERGENCY SERVICES, CORONARY CARE OPEN HEART SURGERY, ONCOLOGY, HIGH RISK MATERNITY AND NEONATAL CARE, AND GENERAL MEDICAL-SURGICAL, OBSTETRICAL, PEDIATRIC REHABILITATIVE, AND BEHAVIORAL SERVICES. 15 13 5431 613 8608997 -1990929 1036554 760857 617110561 643415269 54576333 9554787 -2308164 -2758020 670415284 650972893 0 0 0 0 372718647 392891408 0 0 0 252459977 267259635 625178624 660151043 45236660 -9178150 557564309 574490605 241051561 250822311 316512748 323668294 X INSPIRING EACH OTHER TO GIVE OUR PATIENTS AND THEIR FAMILIES COMPASSIONATE, REMARKABLE CARE. 0 0 569924373 585325187 NORTH MEMORIAL HEALTH CARE IS A GENERAL ACUTE CARE HOSPITAL PROVIDING HIGHLY SPECIALIZED TRAUMA AND EMERGENCY SERVICES, CORONARY CARE OPEN HEART SURGERY, ONCOLOGY, HIGH RISK MATERNITY AND NEONATAL CARE, AND GENERAL MEDICAL - SURGICAL, OBSTETRICAL, PEDIATRIC REHABILITATIVE, AND BEHAVIORAL SERVICES. IN ADDITION TO CHARITY AND UNCOMPENSATED CARE, NMHC ALSO PROVIDES NUMEROUS COMMUNITY BENEFITS (AT NO COST OR BELOW COST).IN FURTHERANCE OF ITS CHARITABLE PURPOSE, NORTH MEMORIAL PROVIDES A WIDE VARIETY OF BENEFITS TO THE COMMUNITY, INCLUDING OFFERING VARIOUS COMMUNITY BASED PROGRAMS, SUCH AS HEALTH SCREENINGS, SUPPORT COUNSELING FOR PARENTS 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, UNREIMBURSED COSTS OF MEDICAL EDUCATION, TELEPHONE INFORMATION SERVICES, AND COST RELATED TO PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. NORTH MEMORIAL ALSO PROVIDES MEDICAL CARE WITHOUT CHARGE OR AT REDUCED COSTS TO RESIDENTS OF ITS COMMUNITY, PRIMARILY THROUGH: (A) THE DIFFERENCE BETWEEN PUBLIC PROGRAM PAYMENTS (PRIMARILY MEDICARE AND MEDICAID) AND THE RELATED COSTS OF PROVIDING SUCH SERVICES; AND (B) SERVICES PROVIDED TO PATIENTS EXPRESSING A WILLINGNESS TO PAY BUT WHO ARE DETERMINED UNABLE TO PAY BECAUSE OF ECONOMIC FACTORS. IN ADDITION, NORTH MEMORIAL CONTRIBUTES TO FUNDING MEDICAL CARE FOR THE UNINSURED THROUGH PAYMENT OF PATIENT SERVICE TAXES, WHICH INCLUDE THE MEDICAID SURCHARGE AND THE MINNESOTA CARE TAX ON CERTAIN NET REVENUE. 569924373 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 1 586 0 1 5431 1 1 1 1 BD 0 0 0 0 0 0 0 0 X 15 13 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 MN X LOREN TAYLOR 7635205200 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 X ROBERT D POTTS 2.00 0.00 X 2700 0 0 TIMOTHY BAYLOR 2.00 0.00 X 2700 0 0 BILL TOBIN 2.00 0.00 X 2700 0 0 DANA CARLSON MD 2.00 0.00 X 1800 0 0 WARREN MACK 2.00 0.00 X 2700 0 0 PAT MCHALE 2.00 0.00 X 0 0 0 JON NIELSON MD 2.00 0.00 X 2700 0 0 BETTY PAKSAD MD 2.00 0.00 X 2700 0 0 ROBERT PRENTISS JR 2.00 0.00 X 2700 0 0 KAREN RAUENHORST 2.00 0.00 X 2700 0 0 MIKE STEINHAUSER 2.00 0.00 X 0 0 0 AMY KOLAR MD 2.00 0.00 X 2700 0 0 JOHN GRAY MD 2.00 0.00 X 0 0 0 STEVE BECK 2.00 0.00 X 0 0 0 LOREN TAYLOR 50.00 0.00 X X 922034 0 26638 PATRICK BORAN 50.00 0.00 X 459510 0 22631 PATRICK BORAN - SERP PAYMENT 50.00 0.00 X 1521420 0 0 KEVIN CROSTON MD 50.00 0.00 X 551607 0 21666 TIFFANY ZITZEWITZ 50.00 0.00 X 332423 0 15694 ANDREW COCHRANE 50.00 2.00 X 438133 0 24432 GAYLE MATTSON 50.00 0.00 X 179002 0 6193 DAVID ABRAMS 50.00 0.00 X 309896 0 26258 JOSEPH BOSTON 50.00 0.00 X 229583 0 20185 MICHAEL PARRISH 50.00 0.00 X 354004 0 26292 PATRICK TAFFE 50.00 0.00 X 345091 0 26280 TOM TIMMONS MD 50.00 0.00 X 446955 0 26334 RYAN JOHNSON 50.00 0.00 X 210743 0 25262 KELLY SPRATT 50.00 0.00 X 208375 0 19071 VIRGINIA MALONE 50.00 0.00 X 631904 0 23993 JOHN ALLEN 50.00 0.00 X 358210 0 4848 JERROLD STEMPEL 50.00 0.00 X 821085 0 10622 ALOK MAHESHWARI 50.00 0.00 X 779626 0 23987 STEVEN ROH 50.00 0.00 X 735924 0 24644 THOMAS ROSSINI 50.00 0.00 X 733593 0 24526 GEORGE TADROS 50.00 0.00 X 702508 0 17500 11297726 0 417056 428 0 1 0 ACCRETIVE HEALTH 39918 TREASURY CENTER CHICAGO IL 606949900 REVENUE CYCLE SUPPORT 10074454 NORTH CLINIC 3366 OAKDALE AVE N 601 ROBBINSDALE MN 55422 PHYSICIAN SERVICES 6525285 ARAMARK HEALTHCARE FOOD 25271 NETWORK PLACE CHICAGO IL 60673 MANAGEMENT SUPPORT FOR DIETARY 3376231 RESPIRATORY CONSULTANTS PA 3366 OAKDALE AVE N 605 ROBBINSDALE MN 55422 INTENSIVISTS STAFFING 2529688 REVENUE CYCLE SOLUTIONS 4524 SOUTHLAKE PARKWAY 15 HOOVER AL 35244 A/R MANAGEMENT SERVICES 1246940 40 478215 282642 79238 760857 HOSPITAL PATIENT REVENUE 621500 589005944 580396947 8608997 CONTRACT REVENUE 900099 26289249 26289249 OTHER 900099 9439937 9439937 JOINT VENTURE REVENUE 990099 7686260 7686260 PHARMACY 990099 4381696 4381696 6612183 6612183 643415269 5576491 5576491 24315 24315 10955589 13713609 -2758020 -2758020 -2758020 60756564 499425 57170211 131797 3586353 367628 3953981 3953981 650972893 585325187 8608997 56277852 6795712 6795712 301186599 263176850 38009749 20960065 18314905 2645160 43804074 38276000 5528074 20144958 17602664 2542294 1181483 1032380 149103 309173 270155 39018 105017 105017 5403694 5403694 52338474 45733359 6605115 1916141 1761704 154437 6161383 5383816 777567 9431391 8241149 1190242 15274595 13346941 1927654 4033288 3524287 509001 33012900 28893067 4119833 5159029 4507960 651069 SUPPLIES 83555864 73011114 10544750 BAD DEBT EXP 19779437 19779437 MAINTENANCE & REPAIR 12814164 11197017 1617147 GOVERNMENT TAXES 9528063 9528063 7255539 6343505 912034 660151043 569924373 90226670 0 9381 19409 15675164 9514694 345991 0 86029544 91286511 5595194 5351746 5825134 4999020 599039604 372770410 229626876 226269194 134867799 157932141 49276441 51392579 30312785 27725311 557564309 574490605 64071117 69203465 443845 443845 124176381 148644676 23513623 0 28846595 32530325 241051561 250822311 X 316512748 323668294 316512748 323668294 557564309 574490605 -9178150 16333696 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 1 40000 1 60000 0 0 100000 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: CONTACTS AND VISITS WERE MADE WITH STATE LEVEL LEGISLATORS TO PROMOTE HEALTH CARE RELATED ISSUES. 2382667 270795 92571 62063 2683970 2251229 72500 71751 12813 2382667 1737891 513452 25341 24455 2252229 1537773 247046 17937 64865 1737891 1910328 -382648 19699 9606 1537773 0.97540 0.02460 0 1 1 15594663 15594663 224843016 106390240 118452776 14112962 8915346 5197616 334744724 251853175 82891549 9744239 5611649 4132590 226269194 RREEF AMERICA REIT II 19825560 F MELLON AGGREGATE BOND INDEX FUND 26056183 F CASH ON DEPOSIT WITH BOND TRUSTEE 5466048 F AGENCY ACCOUNT 44788 F 51392579 EXECUTIVE PENSION PLAN 4027668 RESTORATION PENSION PLAN 54482 PY PENSION LIABILITY 19572930 POST RETIREMENT HEALTH INSURANCE 2577057 SECURITIES LENDING 6130328 CAA DEPOSIT RESERVE 128175 SETTLEMENTS AND CLAIMS PAYABLE 39685 32530325 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ALL ENDOWMENT FUNDS ARE HELD BY A RELATED ENTITY: NORTH MEMORIAL FOUNDATION. 1) RALPH ROSSEN ENDOWMENT: THIS ENDOWMENT WAS ESTABLISHED IN 1986 TO PROVIDE RECOGNITION TO NURSING STAFF THAT PROVIDE REMARKABLE SERVICE TO NORTH MEMORIAL PATIENTS AND THEIR FAMILIES. MEMBERS OF THE ROSSEN FAMILY SERVE ON A COMMITTEE ALONG WITH THE VP AND CHIEF NURSING OFFICER OF NORTH MEMORIAL TO SELECT THE RECIPIENTS. 2) HAROLD B. KAISER HONORARY LECTURESHIP ENDOWMENT: DR KAISER IS THE FOUNDER OF ALLERGY & ASTHMA SPECIALISTS, P.A. ESTABLISHED IN 1966. THE HAROLD B KAISER HONORARY LECTURESHIP ENDOWMENT PROVIDES FUNDING FOR A KEYNOTE SPEAKER FOR THE ANNUAL ALLERGY & ASTHMA CONFERENCE HELD IN THE MINNEAPOLIS AREA IN MARCH. 3) HAROLD ECKER ENDOWMENT: ESTABLISHED IN 1994 IN HONOR OF THE EXCELLENT CARE THAT MR. ECKER RECEIVED AS A PATIENT AT NORTH MEMORIAL, THE HAROLD ECKER ENDOWMENT PROVIDES A $500 AWARD TO THREE NORTH MEMORIAL EMPLOYEES RECOGNIZING THEIR OUTSTANDING PERFORMANCE AND PERSONAL ATTITUDE. THE AWARD IS OPENED TO ALL EMPLOYEES AND THE WINNERS ARE SELECTED BY A COMMITTEE OF NORTH MEMORIAL EMPLOYEES AND PRESENTED AT THE ANNUAL QUALITY AWARDS LUNCHEON IN NOVEMBER EACH YEAR. 4) RESIDENTIAL HOSPICE ENDOWMENT: THE RESIDENTIAL HOSPICE ENDOWMENT WAS ESTABLISHED BY DR. JOHN AND PATTY MANION TO PROVIDE ASSISTANCE TO THE RESIDENTIAL HOSPICE PROGRAM AT NORTH MEMORIAL. FUNDS ARE USED TO UPGRADE THE FACILITIES AND EQUIPMENT AT THE NORTH RESIDENTIAL HOSPICE FACILITY IN BROOKLYN CENTER, PROVIDE ADDITIONAL PROGRAM SUPPORT, STAFF TRAINING AND TO ASSIST THOSE FAMILIES THAT CANNOT AFFORD THIS SERVICE. 5) HELEN MURRAY MEMORIAL ENDOWMENT THIS ENDOWMENT WAS ESTABLISHED WITH AN IRREVOCABLE CHARITABLE REMAINDER TRUST BY JEANNE MITHUN TO RECOGNIZE THE OUTSTANDING SERVICE THAT NORTH RESIDENTIAL HOSPICE PROVIDED TO HER MOTHER (HELEN MURRAY) AND HER FAMILY. FUNDS ARE USED TO PROVDE CARE TO INDIVIDUALS UNABLE TO PAY FOR SERVICES AT THE FACILITY. 6) PAY IT FORWARD THE PAY IT FORWARD FUND WAS ESTABLISHED BY BREAST CANCER SURVIVOR MICHELLE MOREY AND HER HUSBAND SCOTT BISSEN. MICHELLE RECOGNIZED A NEED TO HELP WOMEN STRUGGLING FINANCIALLY WHILE GOING THROUGH CANCER TREATMENT. PATIENTS ELIGIBLE FOR ASSISTANCE ARE FROM NORTH MEMORIAL, UNITY AND MONTICELLO HOSPITALS. THE FUND IS ADMINISTERED AT NO FEE THROUGH THE NORTH MEMORIAL FOUNDATION. 7) MEDICAL STAFF ENDOWMENT THIS ENDOWMENT WAS ESTABLISHED IN 2010 BY THE NORTH MEMORIAL MEDICAL STAFF EXECUTIVE COMMITTEE. PROCEEDS FROM THE ENDOWMENT WILL FUND NORTH MEMORIAL PROGRAMS SUCH AS JUNIOR VOLUNTEER SCHOLARSHIP, SAFEJOURNEY, PASTORAL CARE, ETC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: NORTH MEMORIAL EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS, AND THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2012 OR 2011. NORTH MEMORIAL IS NOT CURRENTLY UNDER EXAMINATION BY ANY TAX JURISDICTION. 1 1 1 X 1 X 1 1 0 1 1 10107837 10107837 0.01530 81552760 55551399 26001361 0.03940 91660597 55551399 36109198 0.05470 1803288 1803288 0.00270 4818184 1716975 3101209 0.00470 62331968 48084969 14246999 0.02160 152111 156437 -4326 0.00000 533872 533872 0.00080 69639423 49958381 19681042 0.02980 161300020 105509780 55790240 0.08450 1 7035344 135938805 183755655 -47816850 X 1 1 1 MAPLE GROVE HOSPITAL HOSPITAL 0.75000 0.00000 0.00000 2 NM SURGERY CENTER MAPLE GROVE OUTPATIENT SURG CTR 0.50000 0.00000 0.50000 3 MN DIAGNOSTIC IMAGING PARTNERS OUTPATIENT IMAGING CTR 0.60000 0.00000 0.40000 4 PREFERRED ONE ADMINISTRATIVE SERVICES CLAIMS ADMINISTRATOR 0.25000 0.00000 0.25000 5 PREFERRED ONE COMMUNITY HEALTH PLAN INSURANCE COMPANY 0.50000 0.00000 0.00000 6 INSTITUTE OF ATHLETIC MEDICINE CLINIC 0.37000 0.00000 0.00000 7 MONTICELLO CANCER CENTER OPTNT CANCER CLINIC 0.40000 0.00000 0.00000 8 NORTH RADIATION ONCOLOGY OPTNT RADIATION ONC CLNC 0.50000 0.00000 0.00000 9 BLAINE URGENCY CENTER URGENT CARE 0.50000 0.00000 0.00000 1 1 NORTH MEMORIAL MEDICAL CENTER

3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422

X X X X NORTH MEMORIAL MEDICAL CENTER 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 1 PART III, LINE 4: NORTH MEMORIAL'S AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE DESCRIPTION ABOUT BAD DEBT EXPENSE. THE COST TO CHARGE RATIO WAS USED TO DETERMINE THE AMOUNT ON PART III, SECTION A, LINE 2. WE DO NOT HAVE THE INFORMATION NECESSARY TO DETERMINE WHICH PORTION OF THE AMOUNT REPORTED ON LINE 2 IS COMMUNITY BENEFIT. PART III, LINE 8: THE SHORTFALL REPORTED REPRESENTS THE AMOUNT MEDICARE REIMBURSEMENT IS LESS THAN THE ESTIMATED COST OFPROVIDING SERVICES TO THOSE PATIENTS. THE METHOD USED TO ESTIMATE THOSE COSTS IS THE COST TO CHARGE RATIO APPROACH WHICH CALCULATES THE RATIO OF TOTAL HOSPITAL COSTS / TOTAL HOSPITAL GROSS REVENUE AND THEM APPLIES THAT RATIO TO TOTAL MEDICARE GROSS REVENUE. PART III, LINE 9B: NORTH MEMORIAL HAS POLICIES AND PROCEDURES IN PLACE FOR COLLECTION PRACTICES THAT INCLUDE IDENTIFICATION AND SCREENING FOR CHARITY CARE AND FINANCIAL ASSISTANCE. THE POLICIES ARE AVAILABLE ON THE ORGANIZATIONS INTRANET AND PERTAIN TO ALL ENTITIES UNDER THE NORTH MEMORIAL CORPORATE UMBRELLA. NORTH MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 20D: THE MINNESOTA ATTORNEY GENERAL'S OFFICE REQUIRES HOSPITALS TO RENDER SERVICES TO THOSE PATIENTS WHO DO NOT HAVE INSURANCE AT A REDUCED RATE EQUAL TO THE DISCOUNT INCURRED FROM THE HIGHEST VOLUME MANAGE CARE PLAN. NORTH MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 22: PER THE MINNESOTA ATTORNEY GENERAL'S AGREEMENT, THIRD PARTY LIABILITY AND PROCEDURES THAT ARE NOT MEDICALLY NECESSARY ARE NOT COVERED UNDER THE MINNESOTA ATTORNEY GENERAL'S AGREEMENT AND THOSE PATIENTS CAN BE BILLED FULL CHARGES. PART VI, LINE 2: NORTH MEMORIAL WORKS CLOSELY WITH COMMUNITY MEMBERS TO DETERMINE AREAS OF INTEREST AND NEED IN HEALTHCARE SERVICES. STARTING IN LATE 2012 AND INTO 2013 WE STARTED COMPLETING A FULL COMMUNITY NEEDS ASSESSMENT, INCLUDING COMMUNITY FOCUS GROUPS, TO BETTER UNDERSTAND THE COMMUNITY'S HEALTH NEEDS. PART VI, LINE 3: NORTH MEMORIAL HEALTH CARE HAS A VERY PROACTIVE PROGRAM TO ASSIST UNINSURED AND UNDERINSURED PATIENTS WITH THEIR MEDICAL BILLS. WE COMPLY WITH THE ATTORNEY GENERAL'S REQUIREMENT TO PROVIDE AN IMMEDIATE DISCOUNT TO UNINSURED MINNESOTA RESIDENTS. WE HAVE PATIENT FINANCIAL ADVOCATES AS WELL AS A CONTRACTED VENDOR THAT MEETS WITH ALL OF OUR UNINSURED INPATIENTS AND SPECIFIC OUTPATIENTS TO ASSIST THEM IN MEDICAL ASSISTANCE ELIGIBILITY AND APPLICATIONS. THIS COULD INCLUDE A VISIT TO THEIR RESIDENCE IF THEY NEED HELP IN COMPLETING ASSISTANCE APPLICATIONS. SHOULD THEY NOT QUALIFY FOR STATE OR FEDERAL ASSISTANCE PROGRAMS, WE OFFER AND ASSIST THEM IN APPLYING FOR THE HOSPITAL'S FINANCIAL ASSISTANCE (CHARITY CARE) PROGRAM.OUR CHARITY CARE PROGRAM IS PUBLISHED IN THE CORPORATE POLICIES AND PROCEDURES AND PROVIDES FOR 100% COVERAGE OF MEDICAL BILLS FOR ANYONE WHOSE INCOME IS LESS THAN 200% OF THE FEDERAL POVERTY GUIDELINES AND NEEDS ASSISTANCE IN RESOLVING THEIR FINANCIAL OBLIGATION TO THE HOSPITAL. THERE IS A GRADUAL REDUCTION IN THE CHARITY COVERAGE BETWEEN THE 201% AND 400% OF THE FEDERAL POVERTY GUIDELINES.IF WE ARE UNABLE TO MEET WITH THE PATIENT BEFORE DISCHARGE FROM NORTH MEMORIAL, THE PATIENT IS GIVEN A PAMPHLET THAT LISTS CONTACT NUMBERS TO OUR BUSINESS OFFICE CUSTOMER SERVICE AREA TO DISCUSS OPTIONS FOR ASSISTANCE WITH THEIR MEDICAL BILLS. THIS CONTACT INFORMATION IS ALSO PROVIDED ON EVERY STATEMENT THAT IS SENT TO OUR CUSTOMERS. IN ADDITION, OUR INTERNAL COLLECTIONS DEPARTMENT AND OUR COLLECTION AGENCIES ARE WELL VERSED IN OUR ASSISTANCE PROGRAMS AND WILL ASSESS DURING THEIR CONVERSATIONS WITH PATIENTS IF REFERRAL TO EITHER A STATE OR FEDERAL PROGRAM OR OUR CHARITY CARE PROGRAM WOULD BE APPROPRIATE. PART VI, LINE 4: NORTH MEMORIAL SERVES A GEOGRAPHIC AREA THAT INCLUDES 42 ZIP CODES IN THE NORTHWEST QUADRANT OF THE TWIN CITIES METRO. THIS SERVICE AREA INCLUDES BOTH URBAN, SUBURBAN, EX-URBAN, AND RURAL AREAS. THIS SERVICE AREA INCLUDES A DIVERSE POPULATION OF MORE THAN 900,000 PEOPLE LIVING IN HENNEPIN, WRIGHT, SHERBURNE AND RAMSEY COUNTIES. PART VI, LINE 5: NORTH MEMORIAL HEALTH CARE IS A GENERAL ACUTE CARE HOSPITAL PROVIDING SPECIALIZED TRAUMA AND EMERGENCY SERVICES, CARDIOVASULAR AND OPEN HEART SERVICES, ONCOLOGY, HIGH RISK MATERNITY AND NEONATAL CARE, AND GENERAL MEDICAL-SURGICAL, OBSTETRICAL, PEDIATRIC, REHABILITATIVE AND BEHAVIORAL SERVICES. NMHC ALSO PROVIDES AN ARRAY OF HEALTH CARE SERVICES TO OUR COMMUNITY INCLUDING PRIMARY CARE, AMBULANCE TRANSPORTATION AND HOME HEALTH AND HOSPICE SERVICES. NORTH MEMORIAL IS GOVERNED BY A BOARD OF 15 REPRESENTATIVES CONSISTING OF PHYSICIANS AND VARIOUS LEADERS FROM THROUGHOUT THE COMMUNITY. BOARD MEMBERS ARE ELECTED TO SERVE THREE-YEAR TERMS FOR A TOTAL OF FIVE TERMS. THE MEDICAL CENTER ALSO SUPPORTS AN OPEN MEDICAL STAFF ORGANIZATION INCLUDING APPROXIMATELY 900 BOARD CERTIFIED PHYSICIANS AND 300 ALLIED HEALTH PROFESSIONSALS. THE NORTH MEMORIAL BOARD OF TRUSTEES ESTABLISHES AN ANNUAL MARGIN TARGET FOR MANAGEMENT. PER BOARD POLICY 75% OF ANY EXCESS AVAILABLE CASH FLOW IS REINVESTED IN THE FORM OF CAPITAL IMPROVEMENTS TO THE CENTER. THE REMAINING 25% IS REINVESTED TO SUPPORT LONG TERM OPERATIONS. PART VI, LINE 6: NORTH MEMORIAL HEALTH SYSTEM IS COMMITTED TO IMPROVING THE HEALTH OF THE COMMUNITIES WE SERVE. THROUGH TARGETED OUTREACH, EDUCATION AND PARTNERSHIPS, WE IMPROVE THE HEALTH OF OUR COMMUNITIES BY LISTENING TO THEIR NEEDS AND RESPONDING WITH APPROPRIATE PROGRAMS AND SERVICES.OUR PROGRAMS, MANY OF WHICH HAVE BEEN NATIONALLY RECOGNIZED, RANGE FROM HEALTH EDUCATION AND FREE SCREENINGS TO TRAINING HEALTH PROFESSIONALS. X 1 1 X X X X 1 1 0 0 0 0 0 0 0 LOREN TAYLOR 606008 0 145819 0 170207 0 17500 0 9138 0 948672 0 151502 0 PATRICK BORAN 340106 0 58456 0 60948 0 17500 0 5131 0 482141 0 0 0 PATRICK BORAN - SERP PAYMENT 0 0 0 0 1521420 0 0 0 0 0 1521420 0 1375503 0 KEVIN CROSTON MD 404932 0 68760 0 77915 0 17500 0 4166 0 573273 0 0 0 TIFFANY ZITZEWITZ 248077 0 21488 0 62858 0 13750 0 1944 0 348117 0 0 0 ANDREW COCHRANE 330000 0 56719 0 51414 0 17500 0 6932 0 462565 0 0 0 GAYLE MATTSON 136381 0 15000 0 27621 0 0 0 6193 0 185195 0 0 0 DAVID ABRAMS 225000 0 38672 0 46224 0 17500 0 8758 0 336154 0 38632 0 JOSEPH BOSTON 164580 0 25468 0 39535 0 14351 0 5834 0 249768 0 0 0 MICHAEL PARRISH 260000 0 44694 0 49310 0 17500 0 8792 0 380296 0 0 0 PATRICK TAFFE 254232 0 44041 0 46818 0 17500 0 8780 0 371371 0 0 0 TOM TIMMONS MD 329930 0 56715 0 60310 0 17500 0 8834 0 473289 0 0 49498 RYAN JOHNSON 177058 0 11122 0 22563 0 13173 0 12089 0 236005 0 0 0 KELLY SPRATT 172308 0 0 0 36067 0 7000 0 12071 0 227446 0 0 0 VIRGINIA MALONE 226385 0 46413 0 359106 0 17500 0 6493 0 655897 0 0 0 JOHN ALLEN 17308 0 0 0 340902 0 2397 0 2451 0 363058 0 42188 0 JERROLD STEMPEL 420000 0 384644 0 16441 0 7500 0 3122 0 831707 0 0 0 ALOK MAHESHWARI 736221 0 33000 0 10405 0 17500 0 6487 0 803613 0 0 0 STEVEN ROH 679208 0 38000 0 18716 0 17500 0 7144 0 760568 0 0 0 THOMAS ROSSINI 718940 0 0 0 14653 0 17500 0 7026 0 758119 0 0 0 GEORGE TADROS 692300 0 0 0 10208 0 17500 0 0 0 720008 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 1A: THE ORGANIZATION REIMBURSES ONE OF THE EXECUTIVE MEMBERS FOR THE MONTHLY SOCIAL DUES AT THE GOLDEN VALLEY COUNTRY CLUB. THE DUES FOR 2012 WERE $90 PER MONTH OR 1,080 PER YEAR. THE NORTH MEMORIAL COMMUNITY FOUNDATION UTILIZES THE COUNTRY CLUB TO HOST VARIOUS FUND RAISING EVENTS THROUGH-OUT THE YEAR THAT SUPPORT VARIOUS ACTIVITIES FOR NORTH MEMORIAL. SUPPLEMENTAL INFORMATION PART III PART I, LINE 2: ALL EXPENSES ARE REVIEWED PRIOR TO REIMBURSEMENT AND SIGNED OFF BY THE CEO. NORTH MEMORIAL REPORTS EXECUTIVE EXPENSE REIMBURSEMENT DATA TO THE BOARD OF TRUSTEES ON A PERIODIC BASIS. SUPPLEMENTAL INFORMATION PART III PART I, LINE 4A: THE AMOUNTS REPORTED IN "OTHER REPORTABLE COMPENSATION" REFLECT PAYMENTS MADE IN 2012 PURSUANT TO SEVERANCE AGREEMENTS WITH 2 EMPLOYEES AS FOLLOWS: VIRGINIA MALONE - $270,000 JOHN ALLEN - $281,000 SUPPLEMENTAL INFORMATION PART III PART I, LINE 4B: MR. PATRICK BORAN - SERP PAYMENT MR. BORAN HAS BEEN EMPLOYED BY NORTH MEMORIAL HEALTH CARE FOR TWENTY-NINE YEARS, THE MOST RECENT EIGHTEEN YEARS AS THE CHIEF FINANCIAL OFFICER OF THE ORGANIZATION. THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WAS ESTABLISHED TO COMPENSATE KEY EMPLOYEES FOR QUALIFIED RETIREMENT PLAN LIMITS. ANNUAL AMOUNTS RELATED TO THIS RETIREMENT BENEFIT WERE ACCRUED AND REPORTED ON THE FORM 990 AS DEFERRED COMPENSATION IN PRIOR YEARS. THE DETERMINATION OF PATRICK BORAN'S TOTAL COMPENSATION (ANNUAL SALARY, DEFERRED COMPENSATION AND EMPLOYEE BENEFITS) IS BASED ON ADVICE FROM A NATIONALLY RECOGNIZED COMPENSATION CONSULTANT REGARDING THE MARKET VALUE OF THE SERVICES MR. BORAN PROVIDES. PATRICK BORAN'S TOTAL COMPENSATION IS APPROVED ANNUALLY BY THE BOARD OF TRUSTEES OF NORTH MEMORIAL HEALTH CARE. IN 2012, A SERP PAYMENT WAS MADE TO PATRICK BORAN IN THE AMOUNT OF $1,521,420. THIS PAYMENT WAS MADE UPON THE ELECTION OF THE PLAN PARTICIPANT (PATRICK BORAN) AS HE MET THE REQUIREMENTS OF AGE PLUS YEARS-OF-SERVICE REQUIRED FOR A PLAN DISTRIBUTION. THIS IS A ONE-TIME PAYMENT AS REQUIRED BY THE AGREEMENT. A CITY OF MAPLE GROVE 410873250 56516TAD7 2005-09-22 55000000 CONSTRUCTION OF OUTPATIENT CENTER 0 1 0 B CITY OF ROBBINSDALE 716005496 2011-06-07 60000000 REFUND SERIES 2008 BONDS 0 1 0 C CITY OF ROBBINSDALE 716005496 2011-06-07 15000000 REFUND SERIES 2008 BONDS 0 1 0 A 54851782 4767980 1083801 49000001 2007 0 0 1 1 B 4458365 60000000 749350 58710650 2011 1 0 1 1 C 667500 15000000 15000000 2011 1 0 1 1 A 0 1 0 0 0 0 1 B 0 0 0 0 0 0 1 C 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 A 1 B 1 C 1 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF MAPLE GROVE DATE THE REBATE COMPUTATION WAS PERFORMED: 08/31/2010 ROBIN DRUG AND MERWIN PHARMACIES BOARD MEMBER IS THE OWNER OF ROBIN DRUG AND MERWIN PHARMACIES 875820 MICHAEL STEINHAUSER, A BOARD MEMBER, IS THE OWNER OF ROBIN DRUG AND MERWIN PHARMACIES, WHICH SUPPLIES DRUGS AND PHARMACEUTICALS TO NORTH MEMORIAL HEALTH CARE. 0 OAKDALE OBGYN BOARD MEMBER IS AN OWNER OF OAKDALE OBGYN 609290 JON NIELSEN, A BOARD MEMBER, IS AN OWNER OF OAKDALE OBSTETRICS & GYNECOLOGY (A.K.A. OAKDALE OBGYN) WHICH PROVIDES GYNECOLOGICAL SERVICES TO NORTH MEMORIAL HEALTH CARE. 0 X MEDICAL EQUIPMENT 1 27572 COST X NURSE CALL SYSTEM 1 17570 COST X VIDEO CONFERENCING EQUIPMENT 1 15616 COST X SOFTWARE 1 18480 COST 0 0 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: PART I, COLUMN (B): LISTS THE NUMBER OF ITEMS CONTRIBUTED. FORM 990, PART VI, SECTION A, LINE 2 LOREN TAYLOR AND BOB POTTS - BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FINANCE AND AUDIT COMMITTEE REVIEWS THE FORM 990 BEFORE IT IS FILED. REPRESENTATIVES FROM THE HOSPITAL'S INDEPENDENT ACCOUNTING FIRM REVIEW THE FORM 990 WITH THE FINANCE AND AUDIT COMMITTEE IN DETAIL AND NOTES FOR THE COMMITTEE ANY CHANGES IN THE FORM 990 FROM PRIOR YEARS. AFTER THOROUGH DISCUSSION, THE FINANCE AND AUDIT COMMITTEE APPROVES THE FORM 990 AND FORWARDS IT TO THE FULL BOARD FOR ITS REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL MEMBERS OF THE BOARD OF DIRECTORS AND ALL EMPLOYEES RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY EACH YEAR. EACH BOARD MEMBER AND STAFF MEMBER FILLS OUT A CONFLICT OF INTEREST QUESTIONNAIRE IN WHICH THEY ARE ASKED TO IDENTIFY ANY RELATIONSHIP THAT WOULD CREATE A CONFLICT OF INTEREST. THE RESULTS ARE SUMMARIZED AND REVIEWED TO DETERMINE ANY ACTUAL OR POTENTIAL CONFLICT AND ARE REPORTED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR KEY POSITIONS ARE REVIEWED BY THE EXECUTIVE COMMITTEE WORKING IN CONJUNCTION WITH AN OUTSIDE CONSULTANT. THE EXECUTIVE COMMITTEE INSURES THAT THE SALARY AND BENEFIT ADMINISTRATION REVIEW PROCESS IS BEING FOLLOWED, WHICH INCLUDES SALARY AND BENEFIT SURVEYS AND COMPARISONS OF ALL POSITIONS. THE CEO'S COMPENSATION IS SENT TO THE FULL BOARD FOR APPROVAL. THE COMPENSATION OF ALL OTHER KEY POSITIONS IS APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FINANCIAL STATEMENTS ARE AVAILABLE ONLINE THROUGH THE OFFICE OF THE ATTORNEY GENERAL VIA THE CHARITY REPORT FILED WITH THE STATE OF MINNESOTA. FORM 990, PART VII, SECTION B: INDEPENDENT CONTRACTORS NORTH MEMORIAL HEALTH CARE PAID ACCRETIVE HEALTH $10,074,454 FOR LABOR AND OTHER COSTS INCURRED DURING THE TAX YEAR. REBATES TOTALING $9,629,771 WERE SUBSEQUENTLY RETURNED TO NORTH MEMORIAL. THE AMOUNT REPORTED IN PART VII, SECTION B, COMPENSATION PAID TO INDEPENDENT CONTRACTORS, REFLECTS THE GROSS AMOUNT PAID TO ACCRETIVE HEALTH DURING 2012. FORM 990, PART XII, LINE 2C: NEITHER THE OVERSIGHT OF THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT WERE CHANGED DURING THE TAX YEAR. OAKDALE MEDICAL CENTER 3300 OALDALE AVENUE NORTH ROBBINSDALE MN 55422 320022819 LEASE MEDICAL OFFICE SPACE MN 704640 17560716 NORTH MEMORIAL NORTH MEMORIAL FOUNDATION 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 411777966 FUNDRAISING MN 501(C)(3) 7 NORTH MEMORIAL 0 ASSOCIATED HEALTH ASSURANCE 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 980343815 INSURANCE BD 501(C)(3) 11A NORTH MEMORIAL 1 MAPLE GROVE HOSPITAL CORPORATION 9875 HOSPITAL DRIVE MAPLE GROVE MN 55369 208316475 ACUTE CARE MN 501(C)(3) 3 NORTH MEMORIAL 1 NORTH MEMORIAL AMBULATORY SURGERY CENTER AT MAPLE GROVE 9855 HOSPITAL DRIVE3300 OAKDALE AVE MAPLE GROVE MN 55369 260393039 OUTPATIENT SURGERY MN RELATED 803982 2760962 0 1 0.50000 MONTICELLO CANCER CENTER 1013 HART BLVD MONTICELLO MN 55362 261909519 CANCER CENTER MN RELATED 2180027 2221713 0 1 0.40000 MINNESOTA DIAGNOSTIC IMAGING PARTNERS LLC 2955 XENIUM LANE SUITE 40 PLYMOUTH MN 55441 352162215 RADIOLOGY MN RELATED 1221755 2623211 0 1 0.60000 NORTH RADIATION THERAPY CENTER LLC 6950 FRANCE AVE S SUITE 200 EDINA MN 55435 743069974 RADIOLOGY MN RELATED 1559926 2042411 0 1 0.50000 BLAINE URGENCY CENTER 480 OSBORNE RD NE FRIDLEY MN 55432 461630126 URGENT CARE MN RELATED 0 1 0.50000 OAKDALE HEALTH ENTERPRISES INC 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 411546422 AMBULANCE MN C 714111 1501739 1.00000 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 NORTH MEMORIAL FOUNDATION (CONTRIBUTIONS) C 478215 FMV NORTH MEMORIAL FOUNDATION (LEASE PMTS)(ENDED IN AUG 2012) J 65905 FMV MAPLE GROVE HOSPITAL CORPORATION (RETURN OF CAPITAL) C 9225000 FMV MAPLE GROVE HOSPITAL CORPORATION (DEBT GUARANTEE) D 107703750 FMV MAPLE GROVE HOSPITAL CORPORATION (LEASE PMTS) J 458957 FMV MAPLE GROVE HOSPITAL CORPORATION (MGMT FEE) S 7732114 FMV MAPLE GROVE HOSPITAL CORPORATION (SALARY REIMBURSMENT) Q 6351567 FMV ASSOCIATED HEALTH ASSURANCE (PREMUIMS) M 2378152 FMV OAKDALE HEALTH ENTERPRISES (PAYROLL) P 347994 FMV OAKDALE HEALTH ENTERPRISES (MGMT FEES) S 726215 FMV OAKDALE HEALTH ENTERPRISES (INTEREST ON LOAN) S 0 FMV OAKDALE MEDICAL OFFICE BUILDING (LEASE PAYMENTS) J 676356 FMV OAKDALE MEDICAL OFFICE BUILDING (EXPENSE REIMBURSMENTS) Q 410493 FMV MINNEAPOLIS RADIATION ONCOLOGY (LOAN GUARANTEE) D 143987 FMV NORTH MEMORIAL AMBULATORY SURGERY CENTER (LEASE PMTS) J 1637628 FMV MAPLE GROVE DIAGNOSTIC IMAGING (LEASE PMTS) J 763451 FMV MINNEAPOLIS RADIATION ONCOLOGY (LEASE PMTS) J 227852 FMV MINNEAPOLIS RADIATION ONCOLOGY (DIVIDEND) R 1315000 FMV