2011-08-15T17:31:04-05:00 2010-09-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-10-01 830379473 Stillwater Medical Group STIL 6514304581 1500 CURVE CREST BLVD STILLWATER MN 55082 DOUGLAS E JOHNSON 6514304581 2011-08-12 1 6123764500 2009 2016-02-24 21:20:13Z JEFFREY J ROBERTSON 927 CHURCHILL ST W STILLWATER MN 55082 48872891 0 X WWW.STILWATERMEDICALGROUP.COM X 2003 MN TO MEET THE HEALTHCARE NEEDS OF INDIVIDUALS, FAMILIES & COMMUNITIES OF THE ST. CROIX VALLEY. 7 1 419 6 0 0 4776111 8630531 39850338 40025219 -59486 -26809 99258 211285 44666221 48840226 2916275 0 28857824 29213416 0 0 15396211 15313981 44254035 47443672 412186 1396554 35521402 37438470 4749057 5241269 30772345 32197201 TO MEET THE HEALTHCARE NEEDS OF INDIVIDUALS, FAMILIES & COMMUNITIES OF THE ST. CROIX VALLEY. 0 0 40802081 2916275 40135481 Provided superior healthcare services to the residents of the St. Croix Valley through operations of medical clinics. The clinic provided charity care of $86,326 in 2010 and $64,205 in 2009. 40802081 1 1 0 0 0 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 0 0 0 1 0 0 0 1 19 0 419 1 0 0 0 0 0 0 0 0 0 7 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 MN X X Doug Johnson 6514304581 927 CHURCHILL STREET W STILLWATER MN 55082 Greg Benson 1.00 X 0 0 0 Jeffrey J Robertson 60.00 X X 0 597790 75893 Chuck Stevens MD 40.00 X X 161411 0 13696 Larry Morrissey MD 40.00 X 184067 0 14998 Steve Scallon MD 40.00 X X 231744 0 13116 Charles Hipp MD 40.00 X X 298000 0 17233 Michael Bourne MD 40.00 X X 346053 0 17548 Douglas E Johnson 60.00 X 0 316905 50047 Matt Ritchie 60.00 X 48615 0 1853 Matt Sedgley 40.00 X 295810 0 17548 Ray Watts 40.00 X 294516 0 16574 Kevin Bjork 40.00 X 331432 0 17548 Candy Corey 40.00 X 360000 0 13813 Thomas Stormont 40.00 X 670774 0 17548 Andrew Dorwart MD 40.00 X 291904 0 29875 Bruce Denison MD 40.00 X 288608 0 43204 3802934 914695 360494 72 1 1 0 Select Transcription Services 11040 183rd Circle NW C Elk River MN 55330 Transportation Services 387174 1 8630531 8630531 NET PATIENT REVENUES 621400 40025219 40025219 40025219 -1385 -1385 101023 101023 101023 101023 7241 32665 -25424 -25424 -25424 MISCELLANEOUS REVENUE 624100 110262 110262 110262 48840226 40025219 0 184476 2916275 2916275 1521344 1521344 23989993 22966868 1023125 657965 416043 241922 1587205 462749 1124456 1456909 775809 681100 9249 9249 3913120 2920842 992278 318599 594 318005 3460228 3192170 268058 341886 341886 2330394 2225486 104908 5075 5075 4053 4053 2502740 2502740 714456 714456 Bad debt 572783 572783 EQUIPMENT MAINTENANCE 387667 282631 105036 Miscellaneous expenses 374435 323804 50631 EMPLOYEE TRAINING 153177 140224 12953 DUES & LICENSES 125839 125739 100 100280 23688 76592 47443672 40802081 6641591 0 3518551 4669250 3889650 3602869 548860 799110 189585 172700 39369064 11174523 27374756 28194541 35521402 37438470 4705100 5195291 43957 45978 4749057 5241269 X 30772345 32197201 30772345 32197201 35521402 37438470 X 0 1 1 X 0 X 3956345 4776111 5742558 14475014 31817652 34696859 39787401 39850338 40025219 186177469 31817652 34696859 43743746 44626449 45767777 200652483 0 0 0 200652483 143166 123272 98874 103694 99638 568644 143166 123272 98874 103694 99638 568644 110262 110262 31960818 34820131 43842620 44730143 45977677 201331389 0.99660 0.99700 0.00280 0.00300 X Schedule A, Part II, Line 12, Explanation of Other Income: MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 571589 571589 26497146 6264385 20232761 2564112 614899 1949213 9736217 4295239 5440978 28194541 1 Lakeview Memorial Hospital Association Inc 927 Churchill Street West Stillwater MN 55082 410811697 501(c)(3) 2916275 General Operations 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: All grants are paid to related organizations under common control. X X X X 0 0 0 0 0 0 0 0 0 Jeffrey J Robertson 0 321343 0 75100 0 201347 0 25097 0 50796 0 673683 0 0 Chuck Stevens MD 146244 0 15167 0 0 0 0 0 13696 0 175107 0 0 0 Larry Morrissey MD 172105 0 11962 0 0 0 0 0 14998 0 199065 0 0 0 Steve Scallon MD 206073 0 25671 0 0 0 0 0 13116 0 244860 0 0 0 Charles Hipp MD 264307 0 33693 0 0 0 0 0 17233 0 315233 0 0 0 Michael Bourne MD 317656 0 28397 0 0 0 0 0 17548 0 363601 0 0 0 Douglas E Johnson 0 199775 0 51047 0 66083 0 15206 0 34841 0 366952 0 0 Matt Sedgley 275090 0 20720 0 0 0 0 0 17548 0 313358 0 0 0 Ray Watts 294516 0 0 0 0 0 0 0 16574 0 311090 0 0 0 Kevin Bjork 303000 0 28432 0 0 0 0 0 17548 0 348980 0 0 0 Candy Corey 350000 0 10000 0 0 0 0 0 13813 0 373813 0 0 0 Thomas Stormont 619260 0 51514 0 0 0 0 0 17548 0 688322 0 0 0 Andrew Dorwart MD 264408 0 27496 0 0 0 19285 0 10590 0 321779 0 0 0 Bruce Denison MD 263200 0 25408 0 0 0 25656 0 17548 0 331812 0 0 0 Supplemental Information Part III SCHEDULE J, PART I, LINE 3 THE CEO'S AND CFO'S COMPENSATION IS ESTABLISHED BY A RELATED ORGANIZATION. THE RELATED ORGANIZATION USED THE FOLLOWING TO ESTABLISH THEIR COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. COMPENSATION SURVEY OR STUDY 4. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE Form 990, Part VI, Section A, line 6 THE SOLE MEMBER IS STILLWATER HEALTH SYSTEM. Form 990, Part VI, Section A, line 7a THE MEMBER HAS THE POWER TO RATIFY, APPROVE AND REMOVE ALL MEMBERS OF THE BOARD OF DIRECTORS, WITH OR WITHOUT CAUSE. Form 990, Part VI, Section A, line 7b THE MEMBER HAS RESERVED TO ITSELF THE FOLLOWING POWERS CONCERNING THE GOVERNANCE OF STILLWATER MEDICAL GROUP: 1. RATIFICATION, APPROVAL AND REMOVAL ALL MEMBERS OF THE BOARD OF DIRECTORS, WITH OR WITHOUT CAUSE. 2. APPROVAL OF ANY MISSION OR VISION STATEMENT OR STATEMENT OF CORPORATE PURPOSE ADOPTED BY THE ORGANIZATION. 3. APPROVAL OF THE ORGANIZATION'S STRATEGIC PLANS, CAPITAL BUDGETS, OPERATING BUDGETS AND FINANCIAL POLICIES. 4. APPROVAL OF ANY PLANS OF MERGER OR CONSOLIDATION BY THE ORGANIZATION WITH ANY FOREIGN OR DOMESTIC ORGANIZATION, VOLUNTARY DISSOLUTION OF THE ORGANIZATION, OR SALE, LEASE OR TRANSFER OF THE ORGANIZATION'S REAL ESTATE OR A SIGNIFICANT PORTION OF THE OPERATIONS OR ASSETS OF THE ORGANIZATION. 5. APPROVAL OF THE GRANT OF A SECURITY INTEREST IN ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S ASSETS, OR THE INCURRENCE OF INDEBTEDNESS OR THE GUARANTEE OF ANY INDEBTEDNESS. 6. APPROVAL OF INDIVIDUAL CAPITAL EXPENDITURES BY THE ORGANIZATION, WHETHER BUDGETED OR UNBUDGETED, IN EXCESS OF $500,000. 7. RATIFICATION OF SELECTION AND EVALUATION, AND TERMINATION, OF THE PRESIDENT OF THE ORGANIZATION. 8. APPROVAL OF PHYSICIAN, EMPLOYEE AND EXECUTIVE COMPENSATION PLANS FOR THE ORGANIZATION, INCLUDING CRITERIA FOR INCENTIVE COMPENSATION ARRANGEMENTS. 9. APPROVAL OF ALL SUBSTANTIVE AFFILIATIONS BETWEEN THE ORGANIZATION AND A THIRD PARTY. 10. APPROVAL OF CONFLICTS OF INTEREST POLICIES FOR THE ORGANIZATION. Form 990, Part VI, Section B, line 11 The Medical Group's draft 990 was reviewed and approved by the Lakeview CFO, then distributed electronically to all Stillwater Medical Group and Stillwater Health System board members (voting and non-voting). The Form 990 was reviewed by the Stillwater Health System Audit Committee. A copy of the final Form 990 was sent electronically to all board members prior to filing. Form 990, Part VI, Section B, line 12c The organization requires Interested Persons to disclose potential conflicts of interest. Interested persons are excluded from deliberations and votes pertaining to the transaction or arrangement. Alternatives to the transaction or arrangement are explored. If a more advantageous transaction or arrangement cannot be identified that does not give rise to conflict of interest, the Board considers the transaction or arrangement based on its benefit to the Corporation. If the board has reasonable cause to believe that a member has failed to disclose possible conflicts of interest, it informs the member of the basis for such belief and affords the member an opportunity to explain the alleged failure to disclose. If, after hearing the response of the member and making such further investigation as is warranted, the board determines that the member has in fact failed to disclose an actual or possible conflict of interest, it takes appropriate disciplinary and corrective action. The board of directors and officers are covered under the Organization's conflict of interest policy. Determinations of conflicts of interest are made and reviewed at the clinic provider level and at the Corporation executive and board level. Form 990, Part VI, Section B, line 15b IN 2010, LAKEVIEW HEALTH SYSTEM' COMPENSATION COMMITTEE RETAINED AN INDEPENDENT EXECUTIVE COMPENSATION CONSULTING FIRM TO PROVIDE A COMPREHENSIVE MARKET COMPARISON FOR THE FOLLOWING EXECUTIVE POSITIONS WITHIN LAKEVIEW HEALTH: SYSTEM CEO, SYSTEM CFO, CLINIC PRESIDENT, CLINIC ADMINISTRATOR AND HOSPITAL PRESIDENT. THE DATA FROM THE 2008 ANALYSIS ALLOWED THE COMMITTEE TO LEARN THE COMPENSATION RATES THAT ARE CONSIDERED P50 TO P60 OF MARKET FOR COMPARABLE LAKEVIEW POSITIONS. OTHER CONSIDERATIONS BY THE COMMITTEE INCLUDE: ACHIEVEMENT OF ORGANIZATIONAL OBJECTIVES, INDIVIDUAL PERFORMANCE, EXPERIENCE, SUBJECTIVE EVALUATION BY BOARD MEMBERS, GENERAL ECONOMIC CONDITIONS, COSTS OF REPLACEMENT, PREVAILING COMMUNITY ATTITUDES AND BELIEFS REGARDING EXECUTIVE COMPENSATION. THE PROCESS OF DETERMINING THE OFFICERS AND BOARD MEMBERS'COMPENSATION INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN 2010. Form 990, Part VI, Section C, line 19 THE MEDICAL GROUP'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE MEDICAL GROUP'S FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC THROUGH ITS ANNUAL REPORT. FORM 990, PART III, LINE 4A AMOUNT OF CHARITY CARE PROVIDED FOR THE 2009 FORM 990 THE ORGANIZATION HAS DECIDED TO REPORT THE AMOUNT OF CHARITY CARE PROVIDED TO PATIENTS AT COST, IN THE PRIOR YEAR HOWEVER, THIS AMOUNT WAS REPORTED AT GROSS, THEREFORE, THE FISCAL YEAR 2009 AMOUNT WAS CHANGED FROM $98,712 IN THE 2008 FORM 990 TO $64,205 IN THE 2009 FORM 990. THE ORGANIZATION DECIDED TO REPORT THE CHARITY CARE AT COST IN ORDER TO BE CONSERVATIVE AND CONSISTENT WITH HOW THIS AMOUNT IS PRESENTED ON THE FORM 990S OF THEIR RELATED ORGANIZATIONS. FORM 990, PART VII, SECTION A AVERAGE WEEKLY HOURS THE COMPENSATED BOARD MEMBERS AND OFFICERS FREQUENTLY DEVOTE THEIR TIME TO MULTIPLE RELATED ORGANIZATIONS IN A PARTICULAR WEEK. EACH INDIVIDUAL WORKS AN AVERAGE OF APPROXIMATELY 60 HOURS PER WEEK FOR STILLWATER MEDICAL GROUP AND ITS RELATED ORGANIZATIONS. Lakeview Memorial Hospital Association Inc 927 Churchill St W STILLWATER MN 55082 410811697 HOSPITAL MN 501(C)(3) 3 N/A Stillwater Health System 927 Churchill St W STILLWATER MN 55082 300221189 HEALTH CARE MN 501(C)(3) 11 - TYPE 2 N/A Lakeview Memorial Hospital Foundation 927 Churchill St W STILLWATER MN 55082 411386635 FOUNDATION MN 501(C)(3) 11 - TYPE 2 N/A ST CROIX VALLEY HEALTH AND CARE RESEARCH FOUNDATION 1500 CHURCHILL BLVD STILLWATER MN 55082 411923524 FOUNDATION MN 501(C)(3) PF N/A 0 1 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 1