2012-11-06T14:16:04-06:00 2011-12-31 990 2011-01-01 410760836 MAYO CLINIC HEALTH SYSTEM-FAIRMONT MAYO 5075381297 800 MEDICAL CENTER DRIVE FAIRMONT MN 56031 JAMES J TARASOVITCH 5073852646 2012-11-06 2011 2016-02-24 21:20:13Z FKA FAIRMONT MEDICAL CENTER - MAYO HEALTH SYSTEM GREGORY KUTCHER MD 800 MEDICAL CENTER DRIVE FAIRMONT MN 56031 77968778 0 X WWW.MAYOCLINICHEALTHSYSTEM.ORG X 1940 MN HOSPITAL, NURSING HOME, AND CLINICS 8 4 784 140 0 0 383039 687010 80313422 76892396 -57954 -4866 389728 346997 81028235 77921537 12747 25909 0 0 50748434 49338189 0 0 223129 29217930 30659676 79979111 80023774 1049124 -2102237 46623017 41921968 19199870 16681931 27423147 25240037 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 71999761 77047097 PATIENT SERVICES (SEE SCHEDULE O)PATIENT SERVICES: MAYO 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 2011, 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.MAYO CLINIC HEALTH SYSTEM - FAIRMONT IS A MEDICAL CENTER PROVIDING CARE TO PATIENTS IN THE CLINIC SETTING, THE EYE CLINIC, THE HOSPITAL, AND EMERGENCY ROOM. THE MEDICAL CENTER ALSO PROVIDES LONG-TERM CARE AND OTHER MEDICAL SERVICES TO THE COMMUNITY OF FAIRMONT, MINNESOTA, AND THE SURROUNDING SOUTH CENTRAL MINNESOTA AND NORTH CENTRAL IOWA SERVICE AREA. THE MEDICAL CENTER IS A "SOLE COMMUNITY HOSPITAL". THE MEDICAL CENTER'S OPERATIONS CONSIST OF A 57-BED ACUTE CARE HOSPITAL, AN ATTACHED 40-BED SKILLED CARE NURSING HOME, AN ATTACHED PROVIDER-BASED CLINIC WITH SATELLITE REGIONAL CLINICS LOCATED IN SHERBURN, MINNESOTA AND TRUMAN, MINNESOTA, CONVENIENT CARE CLINIC LOCATED IN THE WALMART STORE IN FAIRMONT, MINNESOTA, AND SATELLITE CLINICS LOCATED IN ARMSTRONG, IOWA, AND SWEA CITY, IOWA.THE MEDICAL CENTER'S MISSION, VISION AND VALUES STATEMENT IS LISTED BELOW:MISSION: 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.VISION: MAYO CLINIC WILL PROVIDE AN UNPARALLELED EXPERIENCE AS THE MOST TRUSTED PARTNER FOR HEALTH CARE.PRIMARY VALUE: THE NEEDS OF THE PATIENT COME FIRST.THE MEDICAL CENTER PROVIDES CHARITY CARE FOR PATIENTS FINANCIALLY UNABLE TO PAY FOR SERVICES PROVIDED. THE MEDICAL CENTER ALSO PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. THE TOTAL COST OF CHARITY CARE PROVIDED IN 2011 WAS APPROXIMATELY $566,400. THE TOTAL COST OF UNCOMPENSATED CARE PROVIDED TO LOW INCOME PATIENTS THROUGH MEDICAID AND MINNESOTACARE (A STATE PROGRAM FOR PROVIDING MEDICAL CARE TO THE LOW INCOME POPULATION) WAS APPROXIMATELY $1,506,000. INCLUDED IS THIS AMOUNT IS THE MEDICAID SURCHARGE OF $640,026 AND THE MINNESOTACARE TAX OF $797,922.THE TOTAL UNREIMBURSED COST OF MEDICARE WAS APPROXIMATELY $8,230,000. 23754 18649 755 MEDICAL EDUCATON (SEE SCHEDULE O)MEDICAL EDUCATION:MAYO CLINIC HEALTH SYSTEM - FAIRMONT (MCHS-FAIRMONT)PROVIDES CLINICAL EXPERIENCE TO STUDENTS OF IOWA LAKES COMMUNITY COLLEGE, MINNESOTA WEST COMMUNITY COLLEGE, SOUTH CENTRAL COLLEGE, RIVERLAND COMMUNITY COLLEGE, AND PRESENTATION COLLEGE.MCHS - FAIRMONT PROVIDED $18,650 IN SCHOLARSHIPS TO LOCAL COMMUNITY STUDENTS PURSUING A HEALTH-RELATED CAREER.MCHS - FAIRMONT ALSO OFFERED BLOOD PRESSURE SCREENINGS, DEPRESSION SCREENINGS, AND FLU IMMUNIZATIONS TO THE COMMUNITY. MCHS - FAIRMONT OFFERS NUMEROUS EDUCATIONAL SEMINARS, CLASSES AND OPPORTUNITIES FOR ITS PATIENTS, THEIR FAMILIES, EMPLOYEES, COMMUNITY MEMBERS, AND THE GENERAL PUBLIC. THE FOLLOWING IS A SAMPLING OF THE EVENTS THAT WERE OFFERED IN 2011: PARENTING CLASSES, FAMILY FUN FAIR, MARTIN COUNTY FAIR, SUPPORT GROUPS, GRIEF, CANCER, DIABETES, SLEEP APNEA, "SPEAKING OF" HEALTH BROADCAST; ON CAMPUS PRESENTATIONS; HOMETOWN HEALTH NEWSLETTER MAILINGS. 7260 7260 COMMUNITY CONTRIBUTIONS (SEE SCHEDULE O)COMMUNITY CONTRIBUTIONS:MAYO CLINIC HEALTH SYSTEM - FAIRMONT (MCHS-FAIRMONT) OFFERED BLOOD PRESSURE SCREENINGS, DEPRESSION SCREENINGS, AND FLU IMMUNIZATIONS TO THE COMMUNITY.MCHS-FAIRMONT PROVIDES FINANCIAL SUPPORT TO THE AMERICAN CANCER SOCIETY, MARCH OF DIMES, PRESENTATION COLLEGE, AND AREA SCHOOLS FOR ATHLETIC AND OTHER YOUTH PROGRAMS. TOTAL DONATIONS IN 2011 WERE APPROXIMATELY $7,260.IN 2011, MCHS-FAIRMONT RECEIVED DONATED SERVICES FROM 135 VOLUNTEERS, WHO PROVIDED 15,700 VOLUNTEER HOURS, VALUED AT APPROXIMATELY $342,103 BASED ON THE INDEPENDENT SECTOR'S AVERAGE ESTAMATED HOURLY VALUE OF SUCH SERVICE. 171729 MCHS-FAIRMONT LEASES SPACE AND PROVIDES SUPPORT SERVICES TO AFFILIATED ORGANIZATIONS TO HELP FURTHER THEIR EXEMPT PURPOSE. 171729 72030775 1 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 50 0 1 784 1 0 0 0 0 0 0 0 0 0 0 X 8 4 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 MN X CORPORATE TAX UNIT 5075381297 200 FIRST ST SW ROCHESTER MN 55905 X BROLSMA GREG 1.00 X 0 0 0 BUNKERS MD BRIAN E 1.00 X 0 324931 4710 GAALSWYK MARK 1.00 X 0 0 0 GREEN MD JEFFREY P 40.00 X X 205462 0 25086 KUTCHER MD GREGORY 5.00 X X 0 423800 42574 LARSON MARY 1.00 X 0 0 0 MANSKE LYNN 1.00 X 0 0 0 MORRIS MD MARIE E 40.00 X X 346759 0 36031 STRUCK ALLEN W 1.00 X X 0 0 0 GRACE RICHARD W 5.00 X 0 296178 28627 TARASOVITCH JAMES J 5.00 X 0 230999 25645 BERTHELSEN MD STEPHEN O 40.00 X 513879 0 33910 HANSEN GAYLE 40.00 X 201480 0 45589 RODRIGUEZ MD RUFUS 40.00 X 1106707 0 45800 SUTER BRIAN 40.00 X 179365 0 37985 GRAN MD CHRISTOPHER 40.00 X 416815 0 22620 HODGES MD LEROY W 40.00 X 608421 0 53497 KIM MD HYUN I 40.00 X 545635 0 34323 NEIST MD ROGER L 40.00 X 514254 0 48867 SZUTZ TIMOTHY 40.00 X 862044 0 47923 HAGEDORN MD STEVEN D 0.00 X 0 221641 62202 VUOCOLO MD PHILIP 0.00 X 236303 0 802 5737124 1497549 596191 51 1 1 0 MAYO CLINIC HEALTH SYSTEM - MANKATO 1025 MARSH STREET MANKATO MN 56002 MEDICAL SERVICES 774894 WEATHERBY LOCUMS PO BOX 972633 DALLAS TX 75397 LOCUM PHYSICIANS 306334 MEDICAL DOCTOR ASSOCIATES PO BOX 277185 ATLANTA GA 30384 LOCUM PHYSICIANS 291061 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 55480 LAB SERVICES 272645 DR JOHN D HOLSTINE 800 MEDICAL CENTER DRIVE FAIRMONT MN 56031 UROLOGIST 241068 16 357313 144364 185333 687010 NET PATIENT REVENUE 620000 74708373 74708373 LAB REVENUE 621510 2004539 2004539 RENT FROM AFFILIATES 531120 162105 162105 SHARED SERVICES REV 561000 9624 9624 LIFELINE 621990 7000 7000 755 755 76892396 16947 16947 13762 974 12788 12788 12788 10341 32154 -21813 -21813 -21813 21137 14113 7024 7024 CAFETERIA/VENDING 722210 276945 276945 MED REC/TRANSCRIPTION 541900 48518 48518 MISC. REVENUE 900099 1722 1722 327185 77921537 77219581 0 14946 7260 7260 18649 18649 2778052 799507 1978545 477865 477865 34949120 33107654 1729711 111755 2615572 2353491 254414 7667 6088748 5470502 600159 18087 2428832 2185462 236250 7120 63176 63176 7809401 6095509 1699439 14453 225923 8503 170141 47279 3990406 3396285 582089 12032 73820 73820 2235070 2015741 219329 318264 247876 66643 3745 171963 164827 6205 931 488722 488722 2669836 2669836 384361 384361 MEDICAL SUPPLIES 7070873 7070873 BAD DEBT 3389202 3389202 MN CARE TAX 797922 797922 MEDICAID SURCHARGE 640026 640026 330711 240702 89949 60 80023774 72030775 7769870 223129 3637188 173886 128180 0 13029451 14228440 1671412 1664016 1962249 1516889 54080849 32806800 23177098 21274049 3017439 3064688 46623017 41921968 5143492 5715493 0 3248 14056378 10963190 19199870 16681931 X 25433785 23274350 1411066 1330339 578296 635348 27423147 25240037 46623017 41921968 X -2102237 -80873 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 0 0 0 0 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MAYO CLINIC HEALTH SYSTEM - MANKATO (MCHS-MANKATO), THE PARENT COMPANY OF THE FILING ORGANIZATION, PROVIDES SUPPORT SERVICES TO THE FILING ORGANIZATION THAT INCLUDES PROVIDING INFORMATION OR EXPRESSING ITS CONCERN TO LEGISLATIVE BODIES AND GOVERNMENT OFFICIALS ON MATTERS DIRECTLY RELATED TO HEALTH, THE DELIVERY OF HEALTH CARE AND MEDICAL EDUCATION AND/OR RESEARCH. IN 2011, MCHS - MANKATO REPRESENTATIVES HAD SEVERAL MEETINGS WITH MEMBERS OF THE LEGISLATIVE AND EXECUTIVE BRANCHES OF GOVERNMENT TO DISCUSS ISSUES RELATING TO HEALTH CARE AND HEALTH CARE REFORM. 0 1 2103153 468387 -570 605282 1965688 1776123 261963 229353 164286 2103153 1466513 429655 54803 174848 1776123 1922455 -281424 174518 1466513 0.32000 0.68000 1 1 1 99580 99580 38320680 21272710 17047970 15660589 11534090 4126499 21274049 DUE FROM AFFILIATES 58774 DEFERRED COMPENSATION 1082662 INTEREST IN NET ASSETS OF FDN 1923252 3064688 DUE TO AFFILIATES 9833526 DEFERRED COMPENSATION LIABILITY 1082662 ASSET RETIREMENT OBLIGATION 47003 10963190 PART IV, LINE 2B: FAIRMONT MEDICAL CENTER HAS A 40 BED SKILLED NURSING HOME. THEY MAINTAIN A "RESIDENT TRUST" ACCOUNT/BANK ACCOUNT FOR THE NURSING HOME RESIDENTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENTS ARE USED TO FURTHER THE CHARITABLE, EDUCATIONAL, AND SCIENTIFIC PURPOSE OF THE MEDICAL CENTER. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: AT DECEMBER 31, 2011 AND 2010, THERE WAS NO SIGNIFICANT LIABILITY FOR UNRECOGNIZED TAX BENEFITS FOR THE FILING ORGANIZATION. 1 1 X 1 X 1 X 450.000000000000 1 1 1 0 1 1 566374 566374 0.00740 12584216 11078239 1505977 0.01970 13150590 11078239 2072351 0.02710 56884 56884 0.00070 5855 5855 0.00010 1676518 1635455 41063 0.00050 7260 7260 0.00010 1746517 1635455 111062 0.00140 14897107 12713694 2183413 0.02850 0 3389202 17772229 21270680 -3498451 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM-FAIRMONT

800 MEDICAL CENTER DRIVE FAIRMONT MN 56031

X X X CLINIC, NURSING HOME MAYO CLINIC HEALTH SYSTEM-FAIRMONT 1 1 1 100.000000000000 1 450.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 0 6 MAYO CLINIC HEALTH SYSTEM-FAIRMONT

412 6TH STREET ARMSTRONG IA 50514

CLINIC MAYO CLINIC HEALTH SYSTEM-FAIRMONT

32 N MAIN STREET SHERBURN MN 56171

CLINIC MAYO CLINIC HEALTH SYSTEM-FAIRMONT

401 N 4TH AVE E TRUMAN MN 56088

CLINIC MAYO CLINIC HEALTH SYSTEM-FAIRMONT

411 S GROVE ST SUITE 3 BLUE EARTH MN 56013

PSYCHOLOGY SERVICES CLINIC MAYO CLINIC HEALTH SYSTEM-FAIRMONT

207 3RD STREET NORTH SWEA CITY IA 50590

CLINIC MAYO CLINIC HEALTH SYSTEM-FAIRMONT

1250 GOEMANN ROAD FAIRMONT MN 56013

CLINIC 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 $ 3389202. PART III, LINE 4: 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.FOOTNOTE FROM MAYO CLINIC 2011 CONSOLIDATED AUDITED FINANCIAL STATEMENTS: ACCOUNTS RECEIVABLE FOR MEDICAL SERVICES - ACCOUNTS RECEIVABLE FOR MEDICAL SERVICES ARE STATED AT NET REALIZABLE VALUE. THE CLINIC ESTIMATES THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED ON HISTORIC WRITE-OFFS AND THE AGING OF THE ACCOUNTS. ACCOUNTS ARE WRITTEN OFF WHEN COLLECTION EFFORTS HAVE BEEN EXHAUSTED.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. 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 SHORTFALL 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 APPROXIMATELY $8,230,000 AS REPORTED IN THE CORE FORM, PART III, PROGRAM SERVICE ACCOMPLISHMENTS.THE MOST COMMON REASONS FOR A DIFFERENCE BETWEEN THE MEDICARE SHORTFALL 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 EVERY REASONABLE ATTEMPT 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. 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 CLINIC'S 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-FAIRMONT PART V, SECTION B, LINE 13G: 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-FAIRMONT PART V, SECTION B, LINE 19D: OUR POLICY ALLOWS FOR A MINIMUM DISCOUNT OF 10% TO ELIGIBLE INDIVIDUALS WHICH RESULTS IN AN AMOUNT LESS THAN THE AVERAGE OF THE THREE BEST NEGOTIATED COMMERCIAL RATES OR THE BEST NEGOTIATED COMMERCIAL RATE. PART VI, LINE 2: MAYO CLINIC HEALTH SYSTEM - FAIRMONT (MCHS-FAIRMONT) COLLABORATES WITH PUBLIC AND PRIVATE GROUPS IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES. MCHS-FAIRMONT WORKS CLOSELY WITH THE HEALTH AND HUMAN SERVICES AGENCY THAT SERVES MARTIN AND FARIBAULT COUNTIES (MINNESOTA) WHICH IS MCHS-FAIRMONT'S MAIN SERVICE AREA, IN UNDERSTANDING THE NEEDS. DATA IS ALSO RESEARCHED, STUDIED, AND USED IN STRATEGIC PLANNING. DATA SOURCES INCLUDE COUNTY DATA, STATE DATA, AND MINNESOTA HOSPITAL ASSOCIATION DATA. IN ADDITION, MCHS-FAIRMONT PRESENTS PUBLIC EDUCATION EVENTS THROUGHOUT THE YEAR AND HAS LOCAL CABLE INFORMATIVE PROGRAMS. 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 WILL WIDELY PUBLICIZE THIS POLICY IN THE COMMUNITIES THAT THE INDIVIDUAL MAYO CLINIC AFFILIATED SITES SERVE. MAYO CLINIC AFFILIATED SITES WILL MAKE A COPY 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 - FAIRMONT IS AN INTEGRATED HEALTHCARE DELIVERY SYSTEM THAT SERVES THE RESIDENTS OF MARTIN, FARIBAULT, WATONWAN, AND JACKSON COUNTIES IN MINNESOTA AND KOSSUTH, EMMETT, AND PALO ALTO COUNTIES IN IOWA. THE MAIN CITY SERVED IS FAIRMONT, MINNESOTA WITH THE BALANCE OF THE SERVICE AREA BEING SMALL TOWNS OR RURAL AGRICULTURAL AREAS. THE AREA POPULATION IS TRENDING OLDER THAN THE STATEWIDE AVERAGE. THE MAIN INDUSTRY IN THE SERVICE AREA IS AGRICULTURAL BASED. 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 ORGANIZATION'S ACTIVITIES.SURPLUS FUNDS:MAYO 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 BODY:THE 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 CLINIC'S 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 X SCHOLARSHIPS 6 18649 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. SCHOLARSHIPS ARE FOR TUITION AND ARE PAID DIRECTLY TO THE COLLEGE THE RECIPIENT IS ATTENDING. X X 1 1 1 1 0 0 0 0 0 0 1 1 BUNKERS MD BRIAN E 0 204710 0 0 0 120221 0 731 0 3979 0 329641 0 0 GREEN MD JEFFREY P 200969 0 0 0 4493 0 16685 0 8401 0 230548 0 3100 0 KUTCHER MD GREGORY 0 363800 0 60000 0 0 0 12250 0 30324 0 466374 0 0 MORRIS MD MARIE E 283799 0 0 0 62960 0 27630 0 8401 0 382790 0 10622 0 GRACE RICHARD W 0 263178 0 33000 0 0 0 12250 0 16377 0 324805 0 0 TARASOVITCH JAMES J 0 230999 0 0 0 0 0 9316 0 16329 0 256644 0 0 BERTHELSEN MD STEPHEN O 487479 0 0 0 26400 0 27768 0 6142 0 547789 0 21091 0 HANSEN GAYLE 199089 0 0 0 2391 0 24668 0 20921 0 247069 0 0 0 RODRIGUEZ MD RUFUS 732458 0 0 0 374249 0 35899 0 9901 0 1152507 0 226810 0 SUTER BRIAN 157645 0 0 0 21720 0 14404 0 23581 0 217350 0 0 0 GRAN MD CHRISTOPHER 406832 0 0 0 9983 0 19820 0 2800 0 439435 0 8151 0 HODGES MD LEROY W 580790 0 0 0 27631 0 29076 0 24421 0 661918 0 21384 0 KIM MD HYUN I 486375 0 0 0 59260 0 24922 0 9401 0 579958 0 55432 0 NEIST MD ROGER L 430330 0 0 0 83924 0 40725 0 8142 0 563121 0 73276 0 SZUTZ TIMOTHY 679841 0 0 0 182203 0 36522 0 11401 0 909967 0 166497 0 HAGEDORN MD STEVEN D 0 217027 0 0 0 4614 0 34634 0 27568 0 283843 0 0 VUOCOLO MD PHILIP 46072 0 0 0 190231 0 0 0 802 0 237105 0 9204 0 PART I, LINE 1A IN 2011, HEALTH CLUB DUES TO "ANYTIME FITNESS" WERE PAID BY FAIRMONT MEDICAL CENTER ON BEHALF OF PAID EMPLOYEES WHO MET THE ATTENDANCE REQUIRMENTS. THREE OF THE LISTED PERSONS RECEIVED AN AWARD OR OTHER TANGIBLE RECOGNITION THAT WAS TREATED AS TAXABLE COMPENSATION. PURSUANT TO INSTITUTIONAL POLICIES, CERTAIN SUCH AWARDS HAVE A TAX GROSS-UP APPLIED IN ORDER NOT TO DIMINISH THE RECOGNITION AND CELEBRATORY NATURE OF THE AWARD. 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. PART I, LINES 4A-B IN 2011, DR. PHILIP VUOCOLO RECEIVED A SEVERENCE PAYMENT IN THE AMOUNT OF $180,667. 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 YEARS FORM 990. JEFFREY P. GREEN, M.D. $ 3,100 MARIE E. MORRIS, M.D. $ 10,622 STEPHEN O. BERTHELSEN, M.D. $ 21,091 RUFUS RODRIGUEZ, M.D. $226,810 CHRISTOPHER GRAN, M.D. $ 8,151 LEROY W. HODGES, M.D. $ 21,834 HYUN I. KIM, M.D. $ 55,432 ROGER L. NEIST, M.D. $ 73,276 TIMOTHY SZUTZ, M.D. $166,497 PHILIP VUOCOLO, M.D. $ 9,204 PART I, LINE 8 A PORTION OF THE COMPENSATION PAID IN 2011 TO THE ORGANIZATION'S FORMER CEO, DR. PHILIP VUOCOLO, WAS EARNED IN 2010 WHEN DR. VUOCOLO WAS WORKING UNDER HIS INITIAL CONTRACT SIGNED IN 2008. SUPPLEMENTAL INFORMATION PART III COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUALS ARE EMPLOYED BY A RELATED ORGANIZATION: GREGORY KUTCHER, M.D. JAMES TARASOVITCH RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS WHO ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: GREGORY KUTCHER, M.D. MARIE MORRIS, M.D. JAMES TARASOVITCH FORM 990, PART VI, SECTION A, LINE 3 MAYO-AFFILIATED ENTITIES ROUTINELY DELEGATED VARIOUS MANAGEMENT AND SUPPORT FUNCTIONS TO RELATED ENTITIES. FORM 990, PART VI, SECTION A, LINE 4 THE FILING ORGANIZATION CHANGED ITS GOVERNING DOCUMENTS IN 2011 TO REFLECT A NAME CHANGE. THIS NAME CHANGE WAS PREVIOUSLY COMMUNICATED TO AND APPROVED BY THE IRS DURING THE TAX YEAR. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE CORPORATE MEMBER IS MAYO CLINIC HEALTH SYSTEM - MANKATO. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER SHALL APPOINT/REPLACE THREE MEMBERS OF THE BOARD. THE REMAINING MEMBERS OF THE BOARD ARE NOMINATED THROUGH VARIOUS PROCESSES WITH APPROVAL BY THE BOARD OF DIRECTORS AND THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, DEBT DECISIONS AND AMENDMENT OF ARTICLES AND BYLAWS. 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. HIGHLIGHTS ARE PRESENTED TO BOARD MEMBERS, AND THE REVIEW IS DOCUMENTED IN MEETING MINUTES. 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. 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. THE SALARY OF THE CEO AND CAO WERE REVIEWED BY THE MAYO CLINIC HEALTH SYSTEM COMPENSATION AND BENEFITS PURSUANT TO THE PROCESS DESCRIBED BELOW FOR MAYO CLINIC HEALTH SYSTEM PHYSICIANS 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 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. FORM 990, PART VI, SECTION C, LINE 19 THE FILING ORGANIZATION'S GOVERNING DOCUMENTS 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 CLINICS CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO THE FILING ORGANIZATION'S FORM 990 AND WOULD BE AVAILABLE UPON REQUEST OF THE FORM 990. AVERAGE HOURS PER WEEK DEVOTED TO POSITION WITH RELATED ORGANIZATION FORM 990, PART VIII, SECTION A BRIAN E. BUNKERS M.D. 40.0 RICHARD W. GRACE 35.0 STEVEN HAGEDORN M.D. 40.0 GREGORY KUTCHER M.D. 35.0 JAMES J. TARASOVITCH 35.0 CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -12,622. CHANGE IN INTEREST IN ASSETS HELD BY THE FOUNDATION -66,110. ALLOWANCE FOR DOUBTFUL PLEDGES -2,141. TOTAL TO FORM 990, PART XI, LINE 5: -80,873. BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(C)(3) 7 MAYO CLINIC HEALTH SYSTEM--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 FOUNTAIN LAKE TREATMENT CENTER 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 411404076 CHEMICAL DEPENDENCY TREATMENT MN 501(C)(3) 3 MAYO CLINIC HEALTH SYSTEM--ALBERT LEA 1 FRANCISCAN SKEMP FOUNDATION OF ARCADIA INC 464 SOUTH JOHNSON STREET ARCADIA WI 54612 391322480 FUNDRAISING FOUNDATION WI 501(C)(3) 9 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN HEALTHCARE INC 1 GCAS 200 FIRST STREET SW ROCHESTER MN 55905 411917517 AMBULANCE SERVICE MN 501(C)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(C)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 GOLD CROSS AMBULANCE INC 200 FIRST STREET SW ROCHESTER MN 55905 391942957 AMBULANCE SERVICE MN 501(C)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 LUTHER LAKESIDE APARTMENTS INC 714 SOUTH BARSTOW STREET EAU CLAIRE WI 54701 391409024 LOW INCOME HOUSING WI 501(C)(3) 9 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - CLINIC MN 501(C)(3) 9 MAYO CLINIC 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 BLVD 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--ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE CLINIC INC 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) PF MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--FRANCISCAN HEALTHCARE FOUNDATION INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391186647 FUNDRAISING FOUNDATION WI 501(C)(3) 11-II MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--MANKATO 1 MAYO CLINIC HEALTH SYSTEM--NEW PRAGUE 301 SECOND STREET NORTHEAST NEW PRAGUE MN 56071 410723639 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC HEALTH SYSTEM--NORTHLAND INC 1222 EAST WOODLAND AVE BARRON WI 54812 390920634 HOSPITAL AND CLINIC WI 501(C)(3) 3 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--OAKRIDGE INC PO BOX 70 / 13025 EIGHTH STREET OSSEO WI 54758 391029430 HOSPITAL AND CLINIC WI 501(C)(3) 3 MAYO CLINIC HEALTH SYSTEM--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC HEALTH SYSTEM--OWATONNA 134 SOUTHVIEW 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--SPRINGFIELD 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO CLINIC HEALTH SYSTEM--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 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 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) 11-I MAYO CLINIC -- SAINT MARYS HOSPITAL 1 SOUTHERN METRO MEDICAL CLINICS INC 301 MAIN STREET NEW PRAGUE MN 56071 411623632 FAMILY PRACTICE CLINICS MN 501(C)(3) 9 MAYO CLINIC HEALTH SYSTEM--NEW PRAGUE 1 FRANKLIN HEATING STATION 119 THIRD ST SW ROCHESTER MN 55902 410264830 UTILITY MN N/A MAYO CLINIC HEALTH SYSTEM--FARIBAULT 635 FIRST STREET SE FARIBAULT MN 55021 411817179 PATIENT CARE - CLINIC MN N/A C MAYO CLINIC HEALTH SYSTEM--DECORAH CLINIC PHYSICIANS 907 MONTGOMERY STREET DECORAH IA 52101 411711329 PATIENT CARE - CLINIC IA N/A C FIOS THERAPEUTICS INC 200 FIRST STREET SW ROCHESTER MN 55905 711029189 RESEARCH MN N/A C HEALTH TRADITION HEALTH PLAN 1808 EAST MAIN STREET ONALASKA WI 54650 391545987 MEDICAL SERVICES COMPANY WI N/A C LOBSS NETWORK SUPPORT 2002 INC 200 FIRST STREET SW ROCHESTER MN 55905 481276150 ADMINISTRATIVE SERVICES MN N/A C MAYO COLLABORATIVE SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 411346366 REFERENCE LAB SERVICES MN N/A C MAYO HOLDING COMPANY 200 FIRST STREET SW ROCHESTER MN 55905 411578020 HOLDING COMPANY MN N/A C MAYO INSURANCE COMPANY LTD 200 FIRST STREET SW ROCHESTER MN 55905 SELF INSURANCE POOL CJ N/A C MAYO MEDICAL LABORATORIES NEW ENGLAND INC 265 BALLARDVALE STREET WILMINGTON MA 01887 043323713 LABORATORY SERVICES MA N/A C MAYO REGIONAL PRACTICES OF ARIZONA 13400 EAST SHEA BOULEVARD SCOTTSDALE AZ 85259 061190278 THIRD PARTY ADMINISTRATION SERVICES AZ N/A C MHS SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 411282517 EQUIPMENT & REAL ESTATE LEASING MN N/A C MMSI INC 21 FIRST STREET SW ROCHESTER MN 55905 411547003 THIRD PARTY ADMINISTRATION SERVICES MN N/A C MAYO CLINIC HEALTH SYSTEM--PHARMACY & HOME MEDICAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 391528920 PHARMACY SERVICES WI N/A C PHYSICIAN AND HOSPITAL PRACTICES INC 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 930926631 HEALTH SERVICES FL N/A C ROCHESTER AIRPORT COMPANY ROUTE 2 ROCHESTER MN 55902 410506870 AIRPORT MANAGEMENT MN N/A C SUPERBLOCK 3 PROPERTY OWNERS ASSOCIATION 13400 E SHEA BLVD SCOTTSDALE AZ 85259 860870505 COMMERCIAL PROPERTY OWNERS ASSOCIATION AZ N/A C THE STABILE BUILDING OWNERS' ASSOCIATION 200 FIRST STREET SW ROCHESTER MN 55905 208994499 COMMERCIAL PROPERTY OWNERS ASSOCIATION MN N/A C MAYO CLINIC GBS MAURITIUS 2ND FLOOR EBENE MEWS 57 EBENE CYBERCITY MP HEALTHCARE MANAGEMENT MP N/A C CHARITABLE LEAD TRUST (1) CHARITABLE TRUST CA N/A T PERPETUAL TRUST (1) CHARITABLE TRUST ND N/A T PERPETUAL TRUST (1) CHARITABLE TRUST LA N/A T PERPETUAL TRUST (2) CHARITABLE TRUST MA N/A T PERPETUAL TRUST (1) CHARITABLE TRUST MO N/A T PERPETUAL TRUST (1) CHARITABLE TRUST AZ N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST CO N/A T CHARITABLE REMAINDER TRUST (6) CHARITABLE TRUST FL N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST FL N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST IL N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST LA N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST MI N/A T CHARITABLE REMAINDER TRUST (66) CHARITABLE TRUST MN N/A T CHARITABLE REMAINDER TRUST (82) CHARITABLE TRUST MN N/A T CHARITABLE REMAINDER TRUST (1) CHARITABLE TRUST NC N/A T CHARITABLE REMAINDER TRUST (2) CHARITABLE TRUST TX N/A T 1 0 1 0 1 0 0 0 0 0 0 1 0 1 1 0 1 1 MAYO CLINIC - METHODIST HOSPITAL A 88309 GAAP MAYO COLLABORATIVE SERVICES INC L 272645 GAAP MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH Q 74175 GAAP MMSI INC Q 5733745 GAAP MMSI INC R 2704470 GAAP MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH N 36932811 GAAP