2012-11-05T15:29:46-06:00 2011-12-31 990 2011-01-01 411404076 FOUNTAIN LAKE TREATMENT CENTER FOUN 5075381297 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 DAVID PILOT 5073776352 2012-11-05 2011 2016-02-24 21:20:13Z X MARK CIOTA MD 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 8429560 0 X WWW.FOUNTAINCENTERS.ORG X 1981 MN CHEMICAL DEPENDENCY TREATMENT X 12 4 0 5 0 0 474309 61708 7230031 8367552 500 0 57 300 7704897 8429560 0 2357998 0 0 4668464 5102323 0 0 0 2142306 2625100 6810770 10085421 894127 -1655861 1658748 0 2887 0 1655861 0 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 1 8662062 2357998 8367852 PATIENT CARE (SCHEDULE O)FOUNTAIN LAKE TREATMENT CENTER (FLTC) IS A MEMBER OF THE MAYO CLINIC HEALTH SYSTEM. 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 PATIENT'S 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.FOUNTAIN LAKE TREATMENT CENTER (FLTC/FOUNTAIN CENTERS) IS A 58 BED CHEMICAL DEPENDENCY TREATMENT CENTER. FOUNTAIN CENTERS ALSO PROVIDES A 10 BED BOARD AND LODGING HOUSING UNIT IN ALBERT LEA, MINNESOTA. FOUNTAIN CENTERS PROVIDES INTENSIVE OUTPATIENT TREATMENT SERVICES IN ALBERT LEA, FAIRMONT, FARIBAULT, MANKATO, OWATONNA, ROCHESTER, AND WASECA MINNESOTA. DURING 2011, RESIDENTIAL ADMISSIONS NUMBERED 1,088 FOR A TOTAL OF 17,157 RESIDENTIAL TREATMENT DAYS. IN ADDITION, 17,323 GROUP SESSIONS WERE OFFERED THROUGH THE OUTPATIENT PROGRAMS IN 2011.FLTC PROVIDES CARE TO PERSONS COVERED BY GOVERNMENT PROGRAMS. SERVICES ARE PROVIDED TO PUBLICLY FUNDED PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. FREE ASSESSMENTS AND INTERVENTION SERVICES ARE ALSO AVAILABLE FOR TREATMENT PATIENTS. AFTERCARE SERVICES ARE ALSO PROVIDED AT NO CHARGE. FOUNTAIN CENTER HAS AN OLDER ADULTS PROGRAM WHERE TREATMENT SUPPORT AND RECOVERY ACTIVITIES ARE PROVIDED EVEN THOUGH THERE IS NO REIMBURSEMENT BY MEDICARE.THE COST OF CHARITY CARE PROVIDED DURING 2011 WAS $115,222. THE UNREIMBURSED COST OF OTHER MEANS TESTED GOVERNMENT PROGRAMS WAS $854,949.FLTC PROVIDES SUPPORT SERVICES TO THE COMMUNITY BY PROVIDING EDUCATION PRESENTATIONS ON CHEMICAL DEPENDENCY TO COMMUNITY GROUPS. IN 2011, THE STAFF GAVE 10 PRESENTATIONS. FLTC ALSO PROVIDES SPACE FOR WEEKLY COMMUNITY SUPPORT GROUPS.AS OF DECEMBER 31, 2011, ALL FLTC ASSETS AND LIABILITIES WERE TRANSFERRED TO MAYO CLINIC HEALTH SYSTEM-ALBERT LEA. THE EFFECTIVE TIME OF THIS MERGER WAS 11:59 PM ON DECEMBER 31, 2011. 8662062 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 4 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 X AGERTER MD DAVID C 1.00 X 0 439287 46318 CIOTA MD MARK 1.00 X X 0 861046 44353 CRUZ-LARES LINDA 1.00 X 0 0 0 FUNK MICHAEL S 1.00 X 0 0 0 GABRIELSON SHARON 1.00 X 0 166660 36971 HEINZ MD DIETER 1.00 X X 0 351109 43573 KEPPLE-JOHNSON JANE K 1.00 X 0 0 0 MILLER MD ROBERT C 1.00 X X 0 489366 42689 RIZZO MD MARCO 1.00 X 0 529139 38256 ROUTH LORI J 1.00 X 0 134972 11866 SAVELKOUL DONALD 1.00 X 0 0 0 VERDOORN JUDY D 1.00 X X 0 0 0 PARKS DOUGLAS A 1.00 X 0 174599 36434 PILOT DAVID 1.00 X 0 187660 33075 WALDHOFF STEPHEN C 1.00 X 0 249049 54308 SHELHAMER MD LEONARD 0.00 X 0 236575 33500 0 3819462 421343 0 1 1 0 MAYO CLINIC HEALTH SYSTEM - ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 PURCHASED SERVICES 1393581 1 1708 60000 61708 NET PATIENT REVENUE 620000 8364910 8364910 SHARED SERVICES 561000 2642 2642 8367552 MISC. REVENUE 900099 300 300 300 8429560 8367852 0 0 2357998 2357998 3747994 3314580 433414 245602 217201 28401 831649 735478 96171 277078 245037 32041 412 412 1181541 694524 487017 3760 342 3418 668807 385421 283386 200 200 248335 246841 1494 12733 12733 60829 27746 33083 32238 11267 20971 BAD DEBT EXPENSE 198256 198256 MN CARE TAX 117414 117414 MEDICAL SUPPLIES 59662 59662 DUES, LICENSES & SUBSCR 32489 32489 8424 5073 3351 10085421 8662062 1423359 0 750 0 0 0 1536991 0 0 0 0 0 0 0 121007 0 0 0 0 0 0 1658748 0 2887 0 2887 0 X 1650034 0 5827 0 1655861 0 1658748 0 -1655861 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5827 5827 5827 5827 5827 5827 5827 5827 1 0 0 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS PROVIDE A STABLE FUNDING SOURCE FOR PATIENT SUPPORT AND EDUCATION PROGRAMS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: AT DECEMBER 31, 2011 AND 2010, THERE WAS NO MATERIAL LIABILITY FOR UNRECOGNIZED TAX BENEFITS FOR THE FILING ORGANIZATION. 1 MAYO CLINIC HEALTH SYSTEM - ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 411404075 501(C)(3) 2047902 BOOK TRANSFER OF NET ASSETS MERGER OF ORGANIZATION MAYO CLINIC HEALTH SYSTEM - ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 411404075 501(C)(3) 310096 BOOK SUPPORT OPERATIONS 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: TRANSFERS OR GRANTS TO AFFILIATED TAX-EXEMPT ORGANIZATIONS WILL BE USED PURSUANT TO THE POLICIES AND PROCEDURES OF THE GRANTEE ORGANIZATIONS AND TO FURTHER THE EXEMPT PURPOSES OF THE GRANTEE ORGANIZATIONS. BOTH THE FILING ORGANIZATION AND THE GRANTEE ORGANIZATION MAINTAIN ADEQUATE BOOKS AND RECORDS OF SUCH TRANSFERS OR GRANTS. NO ADDITIONAL MONITORING IS PERFORMED. 0 1 0 0 0 0 0 0 0 AGERTER MD DAVID C 0 341092 0 0 0 98195 0 32194 0 14124 0 485605 0 94907 CIOTA MD MARK 0 861046 0 0 0 0 0 17150 0 27203 0 905399 0 0 GABRIELSON SHARON 0 165658 0 0 0 1002 0 15443 0 21528 0 203631 0 0 HEINZ MD DIETER 0 351109 0 0 0 0 0 17150 0 26423 0 394682 0 0 MILLER MD ROBERT C 0 444151 0 0 0 45215 0 21221 0 21468 0 532055 0 43178 RIZZO MD MARCO 0 498493 0 0 0 30646 0 18288 0 19968 0 567395 0 28294 PARKS DOUGLAS A 0 173183 0 0 0 1416 0 13141 0 23293 0 211033 0 0 PILOT DAVID 0 187660 0 0 0 0 0 13374 0 19701 0 220735 0 0 WALDHOFF STEPHEN C 0 243356 0 0 0 5693 0 38104 0 16204 0 303357 0 638 SHELHAMER MD LEONARD 0 236575 0 0 0 0 0 16417 0 17083 0 270075 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 FUTURE 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. $94,907 ROBERT C. MILLER, M.D. $43,178 MARCO RIZZO, M.D. $28,294 STEPHEN C. WALDHOFF $ 638 SUPPLEMENTAL INFORMATION PART III COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. 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. ACCOUNTS RECEIVABLE, NET 2011-12-31 1960295 BOOK VALUE OF ASSETS AT END OF YEAR 411404075 MAYO CLINIC HEALTH SYSTEM - ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 501(C)(3) EQUIPMENT 2011-12-31 88769 BOOK VALUE OF ASSETS AT END OF YEAR 411404075 MAYO CLINIC HEALTH SYSTEM - ALBERT LEA 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 501(C)(3) 1 0 0 0 1 1 1 1 0 0 PART I, LINE 2E: THE BOARD OF TRUSTEES FOR FOUNTAIN LAKE TREATMENT CENTER ARE THE SAME MEMBERS FOR MAYO CLINIC HEALTH SYSTEM - ALBERT LEA, WHICH IS THE SURVIVING ENTITY IN THE MERGER OF THE TWO ORGANIZATIONS. PART I, LINE 7C: MAYO CLINIC'S LEGAL DEPARTMENT CONTACTED THE ATTORNEY GENERAL ABOUT THE DISSOLUTION OF FOUNTAIN LAKE TREATMENT CENTER. THE OUTSTANDING LIABILITIES WERE PART OF THE MERGER WITH MAYO CLINIC HEALTH SYSTEM - ALBERT LEA. CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 DUE TO A MERGER BETWEEN FILING ORGANIZATION AND MAYO CLINIC HEALTH SYSTEM - ALBERT LEA, THE PROGRAM SERVICES OF THE FILING ORGANIZATION WILL BE CARRIED ON BY THE SURVIVING ORGANIZATION, WHICH WILL BE CALLED MAYO CLINIC HEALTH SYSTEM - ALBERT LEA. FORM 990, PART VI, SECTION A, LINE 2 DUE TO OVERLAP OF BOARD MEMBERSHIP AND EMPLOYMENT ON RELATED EXEMPT ENTITIES, THE FOLLOWING INDIVIDUALS: AGERTER M.D., DAVID C. CIOTA M.D., MARK CRUZ-LARES, LINDA FUNK, MICHAEL GABRIELSON, SHARON HENIZ M.D., DIETER KEPPLE-JOHNSON, JANE K. MILLER M.D., ROBERT C. PARKS, DOUGLAS A. PILOT, DAVID RIZZO M.D., MARCO ROUTH, LORI J. SAVELKOUL, DONALD SHELHAMER M.D., LEONARD VERDOORN, JUDY D. AND WALDHOFF, STEPHAN C. HAVE A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS: CIOTA M.D., MARK HEINZ M.D., DIETER PILOT, DAVID ROUTH, LORI J. AND SHELHAMER M.D., LEONARD DONALD SAVELKOUL AND STEPHAN C. WALDHOFF HAD A BUSINESS RELATIONSHIP. 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 MERGED WITH MAYO CLINIC HEALTH SYSTEM - ALBERT LEA AT YEAR END OF 2011, SO THE ARTICLES OF MERGER WERE EXECUTED. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE CORPORATE MEMBER IS MAYO CLINIC HEALTH SYSTEM - ALBERT LEA. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER ELECTS THE DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RIGHTS OF APPROVAL FOR VARIOUS ITEMS/ACTIONS, SUCH AS: 1. REMOVAL OR ELECTION OF DIRECTORS 2. CHANGING THE SIZE OF THE BOARD 3. OR AMENDMENT OF ARTICLES OR 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 SITE FINANCE STAFF AND THE SITE ADMINISTRATOR. 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. FORM 990, PART VI, SECT. B, LINE 15 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, CAO, BOARD VICE CHAIR, BOARD TREASURER, AND SEVERAL BOARD MEMBERS WERE REVIEWED BY THE MAYO CLINIC HEALTH SYSTEM COMPENSATION AND BENEFITS COMMITTEE PURSUANT TO THE PROCESS DESCRIBED BELOW FOR MAYO CLINIC HEALTH SYSTEM PHYSICIANS. 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 THIS 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 FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE CONFLICT OF INTEREST POLICY IS AVAILABLE ON THE MAYOCLINIC.ORG WEBSITE. AVERAGE HOURS PER WEEK DEVOTED TO POSITION WITH RELATED ORGANIZATION PART VII SECTION A DAVID C. AGERTER, M.D. 40.00 MARK CIOTA, M.D. 40.00 SHARON GABRIELSON 40.00 DIETER HEINZ, M.D. 40.00 ROBERT C. MILLER, M.D. 40.00 DOUGLAS A. PARKS 40.00 DAVID PILOT 40.00 MARCO RIZZO, M.D. 40.00 LORI J. ROUTH 40.00 LEONARD SHELHAMER, M.D. 40.00 STEPHEN C. WALDHOFF 40.00 INDEPENDENCE FORM 990 PART VI LINE 1B THE BOARD OF TRUSTEES OF MAYO CLINIC, THE PARENT ENTITY OF THE MAYO CLINIC-AFFILIATED ENTITIES, IS COMPRISED OF MORE THAN 50% PUBLIC TRUSTEES. 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 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1