2012-05-08T13:29:14-05:00 2011-06-30 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-07-01 411924645 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE CENT 3207322141 20 SE NINTH STREET LONG PRAIRIE MN 56347 ERIC LOHN 3207322141 2012-05-04 1 6123764500 2010 2016-02-24 21:20:13Z JAMES DAVIS 20 SE NINTH STREET LONG PRAIRIE MN 56347 24702628 0 X WWW.CENTRACARE.COM X 1999 MN TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE COMMUNITY. 4 0 294 200 0 0 8620 28517 18831789 23797199 230812 445085 518589 191354 19589810 24462155 50095 204802 0 0 11670357 14268532 0 0 0 8048432 9059965 19768884 23533299 -179074 928856 18427182 19640698 5386169 5077823 13041013 14562875 THE CENTRACARE HEALTH SYSTEM WORKS TO IMPROVE THE HEALTH OF EVERY PATIENT, EVERY DAY. 0 0 16524896 204802 23797199 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 $1,954,841 OF COMMUNITY BENEFIT AND CONTRIBUTIONS DURING THE YEAR THROUGH HOSPITAL SERVICES, A HEALTH FAIR, A BLOODMOBILE AND OTHER ACTIVITIES. 16524896 1 1 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 26 0 294 1 0 0 0 0 0 0 0 0 X 4 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 JAMES DAVIS 1.00 X 0 488017 34249 ALLEN HORN MD 1.00 X 0 472107 111677 GREGORY KLUGHERZ 1.00 X 0 442538 96554 TERENCE R PLADSON MD 1.00 X 0 845093 189776 DANIEL SWENSON 40.00 X 0 198251 42280 ERIC LOHN 40.00 X 0 181497 21798 THOMAS HOCK 40.00 X 161154 0 36116 LARRY KNUTSON 40.00 X 105723 0 33401 MARIE KATTERHAGEN 40.00 X 104823 0 21852 CHRISTOPHER HAGEN 40.00 X 119594 0 25508 JOHN SECKINGER X 0 263715 0 491294 2891218 613211 4 1 1 0 LITTLE FALLS ANESTHESIA 808 THIRD STREET SOUTHEAST LITTLE FALLS MN 56345 CRNA SERVICES 137500 WEST CENTRAL ANASTHESIA PC 520 COUNTY OAK DRIVE SAUK CENTRE MN 56370 CRNA COVERAGE 126218 ROXANNE CHARLES MD 625 CHARLOTTE LANE LONG PRAIRIE MN 56347 ER COVERAGE 103366 3 17134 9921 1462 28517 PATIENT REVENUES 621110 23288555 23288555 JOINT VENTURE REVENUES 621110 331403 331403 PHARMACY INCOME 621110 177241 177241 23797199 4472 4472 40072 40072 40072 40072 453002 228084 240473 453002 -12389 440613 440613 MISCELLANEOUS 900099 96249 96249 MEAL INCOME 900099 55033 55033 151282 24462155 23797199 0 636439 201000 201000 3802 3802 10260646 7491182 2769464 418975 316029 102946 2947124 2070253 876871 641787 475060 166727 23689 23689 84329 84329 1771183 1420858 350325 13963 362 13601 1186222 813597 372625 317334 7745 309589 336974 47330 289644 78299 42783 35516 1287 821 466 155315 154138 1177 835169 835169 114834 66956 47878 MEDICAL SUPPLIES 2449878 2317187 132691 BAD DEBTS 656664 31885 624779 MEDICAID SURCHARGE 331269 331269 MNCARE TAX 219042 34673 184369 FOOD 219034 29586 189448 265480 164480 101000 23533299 16524896 7008403 0 2111846 1683007 2946918 3571565 342911 337456 135612 151641 13783206 6924861 7081492 6858345 5012890 5910645 642723 696196 152790 431843 18427182 19640698 1780304 1848224 22166 18641 8014 8508 2685319 2611293 890366 591157 5386169 5077823 X 13018406 14539511 22607 23364 13041013 14562875 18427182 19640698 X 928856 593006 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 757 0 23364 1 1 1 1 312427 312427 7682488 3183184 4499304 252382 109692 142690 5440042 3631985 1808057 95867 95867 6858345 ASSETS INTERNALLY DESIGNATED FOR CAPITAL ACQUISITIONS 5910645 F 5910645 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 115000 ASSET RETIREMENT OBLIGATION 97904 DUE TO AFFILIATES 378253 591157 24462155 23533299 928856 593006 593006 1521862 23987153 0 23987153 475002 475002 24462155 23332299 0 23332299 201000 201000 23533299 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 FOLLOWS 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 2007 TO 2010 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 9,921. INVESTMENT INCOME 457,474. CAPITAL CONTRIBUTIONS 17,435. RESTRICTED CONTRIBUTIONS 757. UNRESTRICTED CONTRIBUTIONS 404. NON OPERATING RENTAL INCOME 1,400. LOSS ON SALE OF ASSETS -12,389. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION TO CENTRACARE FOUNDATION 50,000. TRANSFER TO CENTRACARE HEALTH SYSTEM 151,000. 1 1 X 1 X 175.000000000000 1 X 1 1 1 0 1 1 103329 656178 656178 0.02870 3064199 2014770 1049429 0.04590 103329 3720377 2014770 1705607 0.07460 14326 14326 14326 0.00060 530050 530050 0.02320 305 305 305 0.00000 14631 544681 544681 0.02380 117960 4265058 2014770 2250288 0.09840 14326 14326 0.00060 305 305 0.00000 14631 14631 0.00060 1 421625 3845694 5002001 -1156307 X 1 1 1 1 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE

20 SOUTHEAST NINTH STREET LONG PRAIRIE MN 56347

X X X X SKILLED NURSING FACILITY & CLINIC NA 1 PART I, LINE 3C: AT CCHS-LP EACH PATIENT'S INCOME SOURCES ARE LOOKED AT INCLUDING, BUT NOT LIMITED TO, WAGES, PENSIONS, AND INTEREST AND DIVIDENDS. WE DO NOT PERFORM ANY TYPE OF ASSET TEST. PART I, LINE 7: THE COSTING METHODOLOGY IS DERIVED FROM THE COST TO CHARGE RATIO BASED ON THE PREVIOUS YEAR'S MEDICARE COST REPORT WORKSHEET C, PART 1 TOTAL COSTS DIVIDED BY TOTAL CHARGES. PART I, LINE 7G: SKILLED NURSING FACILITY LOSS OF $303,384. 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 $656,664 OF BAD DEBT EXPENSE ELIMINATED. PART II: THE ANNUAL HEALTH FAIR IS A WAY FOR THE ORGANIZATION TO PROMOTE WELLNESS TO THE SURROUNDING AREA ALONG WITH PROVIDING THEM WITH A MULTITUDEOF AREA VENDORS TO SUPPLY THEM WITH VARIOUS HEALTH RELATED INFORMATION. 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 (AT COST) 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 OTHER FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: THE MEDICARE SHORTFALL CALCULATED IN PART III, LINE 7 REPRESENTS THE CO-INSURANCE AND PATIENTS' RESPONSIBILITIES AND NOT NECESSARILY ELIGIBLE FOR COMMUNITY BENEFIT.THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED IN PART III, LINE 6 IS DERIVED FROM THE ORGANIZATION'S 6/30/2011 MEDICARE COST REPORT. 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. PART VI, LINE 2: THE ORGANIZATION'S STRATEGIC PLANNING ASSESS 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 25,000 PEOPLE. THE 2005 DEMOGRAPHIC INFORMATION INDICATES A SENIOR POPULATION (60 YEARS OR OLDER) OF 21% WHICH COMPARES TO 12.6% FOR THE ENTIRE STATE OF MINNESOTA. THE PER CAPITA INCOME OF THE RESIDENTS IN OUR AREA IS EXTREMELY DEPRESSED AT $20,696 COMPARED TO A STATE AVERAGE OF $33,322. AREA CONSISTS OF AGRICULTURE AND SOME INDUSTRY. PART VI, LINE 6: THE FACILITY HAS A COMMUNITY BASED OPERATING COMMITTEE THAT MEETS ON A MONTHLY BASIS TO REVIEW VARIOUS ASPECTS OF THE FACILITY AND PROVIDE INPUT ON THOSE ASPECTS FROM A COMMUNITY PERSPECTIVE. PART VI, LINE 7: 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, 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 LIFE STYLES.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 ACCOMMODATE OUR HISPANIC POPULATION.THE ORGANIZATION PRESENTED THREE HIGH SCHOOL STUDENTS WITH $500 SCHOLARSHIPS. THE SCHOLARSHIPS ARE INTENDED TO INSPIRE AND ENCOURAGE STUDENTS TO DEDICATE THEIR LIVES TO HELPING OTHERS IN THE HEALTH CARE FIELD. 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 GENERAL OPERATTIONS. CENTRACARE HEALTH SYSTEM 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411813221 501(C)(3) 151000 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 271356 0 45939 0 170722 0 13396 0 20853 0 522266 0 0 ALLEN HORN MD 0 333845 0 114022 0 24240 0 81010 0 30667 0 583784 0 0 GREGORY KLUGHERZ 0 335016 0 79200 0 28322 0 77078 0 19476 0 539092 0 0 TERENCE R PLADSON MD 0 647383 0 187422 0 10288 0 166348 0 23428 0 1034869 0 0 DANIEL SWENSON 0 160200 0 36800 0 1251 0 17745 0 24535 0 240531 0 0 ERIC LOHN 0 145065 0 13539 0 22893 0 13349 0 8449 0 203295 0 0 THOMAS HOCK 157848 0 2909 0 397 0 12104 0 24012 0 197270 0 0 0 JOHN SECKINGER 0 0 0 0 0 263715 0 0 0 0 0 263715 0 0 PART I, LINE 4B 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: - RECEIVED DISTRIBUTION OF 457(F): - JAMES DAVIS - $165,316. - GREG KLUGHERZ - $24,832. - ACCRUED 457(F) EARNINGS: - GREG KLUGHERZ - $66,940 - TERRANCE PLADSON - $147,973 - DAN SWENSON - $13,413 - PAUL HARRIS - $33,357 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 A RELATED ORGANIZATION AND IS SUBJECT TO FULL COMPENSATION AND BENEFITS COMPARABILITY STUDIES CONDUCTED BIENNIALLY BY A THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT HOWEVER, THE COMPENSATION PORTION OF THE STUDY IS REVIEWED ANNUALLY BY THE CONSULTANT AND UPDATED FOR THE COMPENSATION COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVAL. THE MOST RECENT FULL REVIEW WAS DONE IN MAY 2010, AND THE MOST RECENT COMPENSATION REVIEW TOOK PLACE IN MAY 2011. 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 CENTRACARE HEALTH SYSTEM, THE SOLE CORPORATE MEMBER, RESERVES ACTION ON THE FOLLOWING ITEMS: ADOPTION AND AMENDMENT TO THE ARTICLES AND BYLAWS; APPOINTMENT OF DIRECTORS; APPROVAL OF THE CORPORATION'S OPERATING AND CAPITAL BUDGETS; APPROVAL OF STRATEGIC PLANS; DISSOLUTION OR DISCONTINUATION OF THE BUSINESS; AND APPROVAL OF ANY TRANSACTION THAT MAY AFFECT THE CORPORATIONS EXEMPT STATUS. 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 ORGANIZATIONS 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 GAINS ON INVESTMENTS: 593,006. 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 SERVICES - 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 1 0 0 0 0 1 1 0 0 0