SIBLEY MEDICAL CENTER: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- SIBLEY MEDICAL CENTER (EIN 41-1801967)
- Tax period
- 2015-01-01 to 2015-12-31
- Filed
- 2016-11-15
- IRS object ID
- 201603209349313155
- Schema version
- 2015v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-11-15T15:43:41-06:00 | ReturnTs |
| Tax Period End | 2015-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 410746749 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLIFTONLARSONALLEN LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 220 SOUTH SIXTH STREET SUITE 300 | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55402 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 411801967 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIBLEY MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | SIBL | BusinessNameControlTxt |
| Phone | 5079642271 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 500 SOUTH MAPLE STREET | AddressLine1Txt |
| City | WACONIA | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 553871791 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | GORDON GABLENZ | PersonNm |
| Person Title | CFO & CIO | PersonTitleTxt |
| Phone | 5079642271 | PhoneNum |
| Signature | 2016-11-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | KACIE MCEWEN | PreparerPersonNm |
| PTIN | P01599614 | PTIN |
| Phone | 6123764500 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Change | Yes (X) | AddressChangeInd |
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RIDGEVIEW SIBLEY MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | GORDON GABLENZ | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 500 SOUTH MAPLE STREET | AddressLine1Txt |
| City | WACONIA | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 553871791 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $15,007,439 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.SIBLEYMEDICAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1948 | FormationYr |
| Legal Domicile State | MN | LegalDomicileStateCd |
| Activity Or Mission | TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 2 | TotalEmployeeCnt |
| Total Volunteers | 36 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $10,361,622 | PYContributionsGrantsAmt |
| CY Contributions Grants | $26,191 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $12,628,554 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $13,700,648 | CYProgramServiceRevenueAmt |
| PY Investment Income | $27,158 | PYInvestmentIncomeAmt |
| CY Investment Income | $29,473 | CYInvestmentIncomeAmt |
| PY Other Revenue | $448,558 | PYOtherRevenueAmt |
| CY Other Revenue | $419,195 | CYOtherRevenueAmt |
| PY Total Revenue | $23,465,892 | PYTotalRevenueAmt |
| CY Total Revenue | $14,175,507 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $4,035,226 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $7,286,070 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,622,151 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $4,882,186 | PYOtherExpensesAmt |
| CY Other Expenses | $4,477,685 | CYOtherExpensesAmt |
| PY Total Expenses | $16,203,482 | PYTotalExpensesAmt |
| CY Total Expenses | $12,099,836 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $7,262,410 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $2,075,671 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $14,071,533 | TotalAssetsBOYAmt |
| Total Assets EOY | $15,221,395 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,617,064 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $5,734,387 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $7,454,469 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $9,487,008 | NetAssetsOrFundBalancesEOYAmt |
| Mission | RIDGEVIEW SIBLEY MEDICAL CENTER EXISTS TO ENHANCE THE LIFELONG HEALTH OF PEOPLE IT SERVES WITH A CULTURE THAT NURTURES THE WHOLE PERSON: MIND, BODY, AND SPIRIT. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $10,838,167 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $13,700,648 | RevenueAmt |
| Desc | LOCATED IN ARLINGTON, MINNESOTA, RIDGEVIEW SIBLEY MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL--PROVIDING URGENT CARE, GENERAL SURGERY, AND 24/7 HOSPITAL AND EMERGENCY SERVICES TO RESIDENTS OF SIBLEY COUNTY AND THE SURROUNDING AREA. RIDGEVIEW SIBLEY ALSO HAS CLINIC LOCATIONS IN ARLINGTON, GAYLORD, HENDERSON AND WINTHROP. RIDGEVIEW SIBLEY MEDICAL CENTER BELIEVES EVERYONE DESERVES TOP-QUALITY MEDICAL CARE AND THAT THE PEOPLE OF SIBLEY COUNTY SHOULDN'T HAVE TO TRAVEL FAR TO GET THE LATEST MEDICAL ADVANCEMENTS. IT'S THIS BELIEF THAT DRIVES US TO BRING SPECIALTY CARE TO OUR COMMUNITY. IT'S WHY WE CONSTANTLY PURSUE THE TECHNOLOGIES, RECRUIT THE EXPERTS, AND EXPAND AND IMPROVE FACILITIES THAT MAKE GREAT HEALTH CARE POSSIBLE. | Desc |
| Total Program Service Expenses | $10,838,167 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | 0 | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | Yes (1) | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 48 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 2 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | Yes (1) | LocalChaptersInd |
| Policies Reference Chapters | Yes (1) | PoliciesReferenceChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | Yes (1) | InvestmentInJointVentureInd |
| Written Policy Or Procedure | Yes (1) | WrittenPolicyOrProcedureInd |
| States Where Copy Of Return Is Fld | MN | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DARLA ANDERSON | PersonNm |
| Phone | 5079648424 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 WEST CHANDLER | AddressLine1Txt |
| City | ARLINGTON | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55307 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (13 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|---|
| KEVIN LINDSTRAND | |||||||
| CHAIR | 0.50 | 0.00 | Yes (X) | Yes (X) | $1,800 | $0 | $0 |
| DENNIS SCHULTZ | |||||||
| TREASURER | 0.50 | 0.00 | Yes (X) | Yes (X) | $1,200 | $0 | $0 |
| LISA PFARR | |||||||
| SECRETARY | 0.50 | 0.00 | Yes (X) | Yes (X) | $1,200 | $0 | $0 |
| TIM DOLAN | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| BRENDA PAUTSCH | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| LYLE RUD | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| DEE THOMAS | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| DAVE WELCH | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| MIKE WERNER | |||||||
| TRUSTEE | 0.50 | 0.00 | Yes (X) | $1,200 | $0 | $0 | |
| TODD SANDBERG | |||||||
| RSMC ADMINISTRATOR | 1.00 | 49.00 | Yes (X) | $0 | $203,799 | $20,793 | |
| DARLA ANDERSON | |||||||
| DIRECTOR OF FINANCE | 1.00 | 49.00 | Yes (X) | $0 | $109,170 | $24,344 | |
| ROBERT STEVENS | |||||||
| PRESIDENT / CEO | 2.00 | 48.00 | Yes (X) | $0 | $479,589 | $21,160 | |
| GORDON GABLENZ | |||||||
| CFO & CIO | 1.00 | 49.00 | Yes (X) | $0 | $367,625 | $30,610 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $11,400 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $1,160,183 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $96,907 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| MERRILL LYNCH | |||||
| 601 2ND AVE S STE 4000 | MINNEAPOLIS | MN | 55402 | FINANCIAL SERVICES | $1,500,000 |
| CPSI | |||||
| 660 WALL ST PO BOX 850309 | MOBILE | AL | 36685 | IT SERVICES | $222,367 |
| ALLINA HEALTH SYSTEM | |||||
| NW 7710 PO BOX 9383 | MINNEAPOLIS | MN | 55440 | MEDICAL SERVICES | $148,211 |
| PREMIER STAFFING INC | |||||
| 243 WINKLER TR | COLOGNE | MN | 55322 | NURSING SERVICES | $141,323 |
| CMDI | |||||
| 150 10TH ST NW PO BOX 158 | MILACA | MN | 56353 | IMAGING SERVICES | $106,333 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 5 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $26,191 | AllOtherContributionsAmt |
| Total Contributions | $26,191 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | NET PATIENT REVENUE | Desc |
| Business | 621300 | BusinessCd |
| Total Revenue Column | $13,700,648 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $13,700,648 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $13,700,648 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $37,636 | TotalRevenueColumnAmt |
| Exclusion | $37,636 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $61,686 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $61,686 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $61,686 | TotalRevenueColumnAmt |
| Exclusion | $61,686 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $812,840 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $821,003 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -$8,163 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$8,163 | TotalRevenueColumnAmt |
| Exclusion | -$8,163 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Fundraising Gross Income | $27,014 | FundraisingGrossIncomeAmt |
| Fundraising Direct Expenses | $10,929 | FundraisingDirectExpensesAmt |
Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $16,085 | TotalRevenueColumnAmt |
| Exclusion | $16,085 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Sales Of Inventory | $4,699 | GrossSalesOfInventoryAmt |
| Cost Of Goods Sold | $0 | CostOfGoodsSoldAmt |
Net Income Or Loss NetIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $4,699 | TotalRevenueColumnAmt |
| Exclusion | $4,699 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| MEANINGFUL USE INCOME | 900099 | $247,671 | $247,671 |
| JOINT VENTURE INCOME | 900099 | $37,415 | $37,415 |
| FINANCE CHARGE | 900099 | $32,074 | $32,074 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $19,565 | TotalRevenueColumnAmt |
| Exclusion | $19,565 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $336,725 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $14,175,507 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $13,700,648 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $448,668 | ExclusionAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,450,031 | TotalAmt |
| Program Services | $5,965,639 | ProgramServicesAmt |
| Management And General | $484,392 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $233,439 | TotalAmt |
| Program Services | $215,696 | ProgramServicesAmt |
| Management And General | $17,743 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $479,601 | TotalAmt |
| Program Services | $401,318 | ProgramServicesAmt |
| Management And General | $78,283 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $459,080 | TotalAmt |
| Program Services | $423,454 | ProgramServicesAmt |
| Management And General | $35,626 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $48 | TotalAmt |
| Management And General | $48 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,558 | TotalAmt |
| Management And General | $45,558 | ManagementAndGeneralAmt |
Fees For Srvc Invst Mgmnt Fees FeesForSrvcInvstMgmntFeesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,489 | TotalAmt |
| Management And General | $9,489 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,042,848 | TotalAmt |
| Program Services | $1,039,000 | ProgramServicesAmt |
| Management And General | $3,848 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $33,306 | TotalAmt |
| Management And General | $33,306 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $136,869 | TotalAmt |
| Program Services | $81,218 | ProgramServicesAmt |
| Management And General | $55,651 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $268,707 | TotalAmt |
| Management And General | $268,707 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $319,079 | TotalAmt |
| Program Services | $319,079 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,352 | TotalAmt |
| Program Services | $51,353 | ProgramServicesAmt |
| Management And General | $3,999 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $49,176 | TotalAmt |
| Program Services | $44,998 | ProgramServicesAmt |
| Management And General | $4,178 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $148,818 | TotalAmt |
| Program Services | $148,818 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $329,487 | TotalAmt |
| Program Services | $228,076 | ProgramServicesAmt |
| Management And General | $101,411 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,916 | TotalAmt |
| Management And General | $7,916 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $1,298,285 | $1,298,285 | |
| OTHER EXPENSES | $403,411 | $291,897 | $111,514 |
| MINNESOTA CARE TAX | $166,607 | $166,607 | |
| BAD DEBT EXPENSE | $162,729 | $162,729 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,099,836 | TotalAmt |
| Program Services | $10,838,167 | ProgramServicesAmt |
| Management And General | $1,261,669 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,831,917 | BOYAmt |
| EOY | $4,161,837 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $744,090 | BOYAmt |
| EOY | $1,194,802 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,489,485 | BOYAmt |
| EOY | $2,136,454 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,290 | BOYAmt |
| EOY | $2,926 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $280,006 | BOYAmt |
| EOY | $298,370 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $62,302 | BOYAmt |
| EOY | $40,187 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $6,538,972 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $536,012 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,413,624 | BOYAmt |
| EOY | $6,002,960 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,010,163 | BOYAmt |
| EOY | $1,213,608 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $228,656 | BOYAmt |
| EOY | $170,251 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,071,533 | BOYAmt |
| EOY | $15,221,395 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $345,738 | BOYAmt |
| EOY | $356,371 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $333,062 | BOYAmt |
| EOY | $439,660 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,618,324 | BOYAmt |
| EOY | $4,384,022 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,319,940 | BOYAmt |
| EOY | $554,334 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,617,064 | BOYAmt |
| EOY | $5,734,387 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,454,469 | BOYAmt |
| EOY | $9,487,008 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,454,469 | BOYAmt |
| EOY | $9,487,008 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,071,533 | BOYAmt |
| EOY | $15,221,395 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $2,075,671 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$43,132 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consol And Sep Basis Fincl Stmt | Yes (X) | ConsolAndSepBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule D IRS990ScheduleD
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,040,816 | OtherCostOrOtherBasisAmt |
| Depreciation | $323,089 | DepreciationAmt |
| Book Value | $4,717,727 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $113,451 | OtherCostOrOtherBasisAmt |
| Book Value | $113,451 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $890,910 | OtherCostOrOtherBasisAmt |
| Depreciation | $212,923 | DepreciationAmt |
| Book Value | $677,987 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $493,795 | OtherCostOrOtherBasisAmt |
| Book Value | $493,795 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $6,002,960 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | THIRD PARTY PAYOR SETTLEMENTS | Desc |
| Amt | $554,334 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $554,334 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $13,986,071 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | $10,929 | OtherRevenueAmt |
| Revenue Not Reported | $10,929 | RevenueNotReportedAmt |
| Revenue Subtotal | $13,975,142 | RevenueSubtotalAmt |
| Other Revenues Not Included | $200,365 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $200,365 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $14,175,507 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $11,948,036 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | $10,929 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $10,929 | ExpensesNotReportedAmt |
| Expenses Subtotal | $11,937,107 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $162,729 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $162,729 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $12,099,836 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE ORGANIZATION IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE THAT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(C)(3) OF THE CODE. THE ORGANIZATION HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT FOR UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | SPECIAL FUNDRAISING EVENT EXPENSES 10,929. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | INVESTMENT INCOME 37,636. COST OF GOODS SOLD PROVISION FOR BAD DEBTS 162,729. |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | SPECIAL FUNDRAISING EVENT EXPENSES 10,929. COST OF GOODS SOLD |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | PROVISION FOR BAD DEBTS 162,729. |
Schedule G IRS990ScheduleG
Fundraising Event Information FundraisingEventInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Event1 | SPRING BENEFIT | Event1Nm |
| Gross Receipts Event1 | $15,534 | GrossReceiptsEvent1Amt |
| Charitable Contri Event1 | $0 | CharitableContriEvent1Amt |
| Gross Revenue Event1 | $15,534 | GrossRevenueEvent1Amt |
| Cash Prizes Event1 | $0 | CashPrizesEvent1Amt |
| Non Cash Prizes Event1 | $297 | NonCashPrizesEvent1Amt |
| Rent Facility Costs Event1 | $300 | RentFacilityCostsEvent1Amt |
| Food And Beverage Event1 | $2,414 | FoodAndBeverageEvent1Amt |
| Entertainment Event1 | $700 | EntertainmentEvent1Amt |
| Other Direct Expenses Event1 | $412 | OtherDirectExpensesEvent1Amt |
| Event2 | FISH HOUSE RAFFLE | Event2Nm |
| Gross Receipts Event2 | $11,480 | GrossReceiptsEvent2Amt |
| Charitable Contri Event2 | $0 | CharitableContriEvent2Amt |
| Gross Revenue Event2 | $11,480 | GrossRevenueEvent2Amt |
| Cash Prizes Event2 | $0 | CashPrizesEvent2Amt |
| Non Cash Prizes Event2 | $6,497 | NonCashPrizesEvent2Amt |
| Rent Facility Costs Event2 | $0 | RentFacilityCostsEvent2Amt |
| Food And Beverage Event2 | $0 | FoodAndBeverageEvent2Amt |
| Entertainment Event2 | $0 | EntertainmentEvent2Amt |
| Other Direct Expenses Event2 | $309 | OtherDirectExpensesEvent2Amt |
| Gross Receipts Total | $27,014 | GrossReceiptsTotalAmt |
| Gross Revenue Total Events | $27,014 | GrossRevenueTotalEventsAmt |
| Non Cash Prizes Total Events | $6,794 | NonCashPrizesTotalEventsAmt |
| Rent Fclty Costs Total Events | $300 | RentFcltyCostsTotalEventsAmt |
| Food And Beverage Total Events | $2,414 | FoodAndBeverageTotalEventsAmt |
| Entertainment Total Events | $700 | EntertainmentTotalEventsAmt |
| Oth Direct Expnss Total Events | $721 | OthDirectExpnssTotalEventsAmt |
| Direct Expense Summary Events | $10,929 | DirectExpenseSummaryEventsAmt |
| Net Income Summary | $16,085 | NetIncomeSummaryAmt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent150 | Yes (X) | Percent150Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
Discounted Care Oth Percentage DiscountedCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Discounted Care Other | 225.000000000000 | DiscountedCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $264,272 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $264,272 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02210 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $322,476 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $263,692 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $58,784 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00490 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $586,748 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $263,692 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $323,056 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02700 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $38,001 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,793 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $36,208 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00300 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $3,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $41,001 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,793 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $39,208 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00330 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $627,749 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $265,485 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $362,264 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03030 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $162,729 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $10,830,029 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,728,697 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $4,101,332 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIBLEY MEDICAL CENTER | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 WEST CHANDLER STREET | AddressLine1Txt |
| City | ARLINGTON | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55307 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.SIBLEYMEDICAL.ORG | WebsiteAddressTxt |
| State License | HFID-00618 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RIDGEVIEW SIBLEY MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 13 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 13 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.SIBLEYMEDICAL.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 150.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 225.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Explained Basis | 0 | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Includes Publicity Measures | 0 | IncludesPublicityMeasuresInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| RIDGEVIEW SIBLEY MEDICAL CENTER | PART V, SECTION B, LINE 5: IN ORDER TO ENSURE THE REVIEW OF THE RESEARCH WAS QUALITY DATA, COMMUNITY LEADERSHIP TEAM (CLT) INITIATED, PLANNED AND IMPLEMENTED THE PROJECT. PERSONNEL THAT PARTICIPATED REPRESENT A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL SERVICES, NON-PROFIT AND SOCIAL ORGANIZATIONS, AND THE BUSINESS COMMUNITY. TWO FOCUS GROUPS WERE FORMED THAT REPRESENTED A TOTAL OF 35 KEY COMMUNITY LEADERS IN MAY AND JUNE OF 2013. THE ASSESSMENT INITIATIVE WAS CONDUCTED IN TWO DISTINCT PHASES. INITIALLY, PHONE CONFERENCES WERE HELD WITH A CONSULTANT FROM STRATUS HEALTH TO DETERMINE HOW TO GATHER KEY STAKEHOLDERS INPUT AND INFORMATION. BETWEEN THE LOCAL PUBLIC HEALTH STAFF AND THE HOSPITAL STAFF, IT WAS DECIDED TO CONDUCT COMMUNITY FOCUS GROUPS. THROUGH COLLABORATION, A LIST OF KEY STAKEHOLDERS WAS DEVELOPED AND INVITATIONS WERE SENT OUT TO THE COMMUNITY. APPROXIMATELY 100 PEOPLE WERE SELECTED TO PARTICIPATE IN THE FOCUS GROUPS. THE SELECTION OF THE PERSONNEL ASKED TO PARTICIPATE WAS BASED ON: - PERSONS WITH SPECIAL KNOWLEDGE OR EXPERTISE IN PUBLIC HEALTH - REPRESENTATIVES FROM HEALTH DEPARTMENTS OR GOVERNMENT AGENCIES SERVING COMMUNITY HEALTH - LEADERS OR MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE - OTHER KEY STAKEHOLDERS IN THE COMMUNITYINVITATIONS WERE SENT BY MAIL AND E-MAIL WITH A REQUEST TO RESPOND FOR ATTENDANCE. OUR RECOMMENDATION WAS TO MEET FOR TWO SESSIONS AND ASSESS THE HEALTH NEEDS OF OUR COMMUNITY. |
| RIDGEVIEW SIBLEY MEDICAL CENTER | PART V, SECTION B, LINE 6B: SIBLEY MEDICAL CENTER COLLABORATED WITH KEY STAKEHOLDERS AND ORGANIZATIONS IN THEIR TRI-COUNTY AREA, INCLUDING SIBLEY, MCLEOD, AND MEEKER COUNTIES. |
| RIDGEVIEW SIBLEY MEDICAL CENTER | PART V, SECTION B, LINE 11: RIDGEVIEW CONTINUES TO DEVELOP BROAD COMMUNITY STRATEGIES THAT FOCUS ON FOUR HEALTH ISSUES THAT WERE IDENTIFIED AND PRIORITIZED IN THE CHNA AND IMPLEMENTATION PLAN: 1) CANCER, 2) OBESITY, 3) AGING-RELATED CONCERNS AND 4) MENTAL HEALTH. DURING THIS FISCAL YEAR, RIDGEVIEW BEGAN LOW-COST OFFERING CALCIUM SCORE SCREENINGS AND A COMMUNITY CARIOLOGY CLINIC. THROUGH THESE ACTIVITIES, WE SERVED 415 INDIVIDUALS IN 2015. |
| RIDGEVIEW SIBLEY MEDICAL CENTER | PART V, SECTION B, LINE 22D: EVERY SELF-PAY PATIENT GETS A DISCOUNT EQUAL TO THE GREATEST COMMERCIAL PAYOR. UPON DETERMINATION OF A PATIENT'S CHARITY CARE ELIGIBLITY, SIBLEY MEDICAL CENTER REVERSES THE ORIGINAL SELF-PAY DISCOUNT THAT WAS GIVEN AND AT A MINIMUM GIVES A 25% DISCOUNT ON THEIR BILL, WHICH IS GREATER THAN THE DISCOUNT GIVEN TO ALL SELF-PAY AND COMMERCIALLY INSURED PATIENTS. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 4 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - RIDGEVIEW ARLINGTON CLINIC | ||||
| 601 WEST CHANDLER STREET | ARLINGTON | MN | 55307 | CLINIC |
| 2 - RIDGEVIEW GAYLORD CLINIC | ||||
| 660 3RD STREET | GAYLORD | MN | 55334 | CLINIC |
| 3 - RIDGEVIEW HENDERSON CLINIC | ||||
| 505 MAIN STREET | HENDERSON | MN | 56044 | CLINIC |
| 4 - RIDGEVIEW WINTHROP CLINIC | ||||
| 223 NORTH CARVER STREET | WINTHROP | MN | 55396 | CLINIC |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | ELIGIBILITY FOR SIBLEY MEDICAL CENTER'S CHARITY CARE PROGRAM IS BASED ON FAMILY INCOME RELATIVE TO FEDERAL POVERTY GUIDELINES (FPG). FREE CARE IS OFFERED FOR FEDERAL ADJUSTED GROSS INCOME UP TO 150% OF FPG. 75% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 175% OF FPG. 50% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 200% OF FPG. AND 25% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME UP TO 225% OF FPG. |
| PART I, LINE 7: | THE COSTING METHODOLOGY USED BY SIBLEY MEDICAL CENTER TO DETERMINE THE COMMUNITY BENEFIT EXPENSES INCLUDED IN PART I, LINES 7A-D WERE DERIVED BY TAKING THE RESPECTIVE AMOUNTS PER THE AUDITED FINANCIAL STATEMENTS AND APPLYING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. THE COMMUNITY BENEFIT EXPENSES INCLUDED IN LINES 7E-J WERE REPORTED BASED ON SMC'S ACTUAL COSTS FOR EACH CLASSIFICATION OF EXPENSES. |
| PART I, LN 7 COL(F): | BAD DEBT EXPENSES INCLUDED ON FORM 990, PART IX, LINE 24, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $162,729 FOR THE YEAR ENDED DECEMBER 31, 2015. |
| PART III, LINE 4: | THE NOTE OF SIBLEY MEDICAL CENTER'S 2015 FINANCIAL STATEMENTS THAT INCLUDES THE EXPLANATION OF BAD DEBT EXPENSE IS THE "PATIENT RECEIVABLES, NET" FOOTNOTE INCLUDED ON PAGE 8. |
| PART III, LINE 8: | SIBLEY MEDICAL CENTER USED THE 2015 FILED MEDICARE COST REPORT TO CALCULATE THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6. THERE WAS NO MEDICARE SHORTFALL CALCULATED IN PART III, LINE 7 FOR THE YEAR ENDED DECEMBER 31, 2015. |
| PART III, LINE 9B: | AT ANY POINT DURING THE BILLING AND COLLECTION PROCESS A PATIENT HAS THE ABILITY TO REQUEST AN APPLICATION FOR FINANCIAL ASSISTANCE. ONCE AN APPLICATION HAS BEEN REQUESTED, THE COLLECTION PROCESS PAUSES AND DOES NOT CONTINUE UNTIL A DETERMINATION IS MADE FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | IN 2013, SIBLEY MEDICAL CENTER PARTNERED WITH NEIGHBORING COMMUNITIES, PUBLIC HEALTH DEPARTMENTS AND STRATIS HEALTH (AN INDEPENDENT, NONPROFIT ORGANIZATION THAT LEADS IN COLLABORATION AND INNOVATION IN HEALTH CARE QUALITY AND SAFETY) TO COMPLETE THE INITIAL DISCOVERY PHASE OF THE ASSESSMENT. THE LEAD CONSULTANT, KIM MCCOY WITH STRATIS HEALTH, FACILITATED THE INITIAL PHASE OF CONDUCTING A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT. THE OVERALL GOAL OF THE ASSESSMENT WAS TO IDENTIFY THE MAJOR HEALTH NEEDS, SERVICE GAPS, BARRIERS TO ACCESS, AND HEALTH PRIORITIES FOR THE COMMUNITY. AS PART OF THE ASSESSMENT, STRATUS HEALTH COLLECTED QUANTITATIVE AND QUALITATIVE INFORMATION FROM A BROAD ARRAY OF SOURCES. THE PURPOSE OF GATHERING THE INFORMATION AND STATISTICS WAS TO ANALYZE THE HEALTH OF THE COMMUNITY AND THEN FACILITATE THE DEVELOPMENT OF SHORT AND LONG-TERM PLANS TO GUIDE THE HEALTH INVESTMENTS OF SIBLEY COUNTY. |
| PART VI, LINE 4: | SIBLEY COUNTY INCLUDES SEVEN CITIES. IN AGGREGATE, THE LAND SIZE IS 600.41 SQUARE MILES WITH A TOTAL POPULATION OF 15,123 PEOPLE. SIBLEY COUNTY IS CONSIDERED A "FRINGE" COUNTY AND IS ON THE WESTERN BOUNDARY OF THE SEVEN-COUNTY TWIN CITIES METROPOLITAN AREA. THE DISTINCT QUALITIES OF EACH COMMUNITY PROVIDE A UNIQUE BLEND OF HISTORY AND CULTURE. MANY COMMUTERS TAKE ADVANTAGE OF OUR LOWER HOUSING COSTS AND THE BENEFITS OF RURAL LIVING.AGRICULTURE IN SIBLEY COUNTY IS A MAIN SOURCE OF EMPLOYMENT AND INCOME. THERE ARE 352,000 ACRES DEDICATED TO FARMING. OF THESE FARMS, 86.55% OF THEM ARE INDIVIDUALLY / FAMILY OWNED AND OPERATED. THE AVERAGE VALUE OF THE AGRICULTURAL PRODUCTS SOLD PER FARM IS $175,079. ALONG WITH THE PRODUCTION OF CROPS, A LARGE NUMBER OF FARMS RAISE LIVESTOCK, POULTRY, AND DAIRY CATTLE.ACCORDING TO THE 2010 US CENSUS, THERE ARE 15,123 PEOPLE LIVING IN SIBLEY COUNTY, WITH THE MAJORITY OF THE POPULATION RESIDING IN THE CITIES OF ARLINGTON, GAYLORD, AND WINTHROP. THE POPULATION BREAKDOWN SHOWS THOSE UNDER 18 YEARS OF AGE AT 24.7%, THOSE 65 YEARS AND OVER AT 16.9%; WITH THE MEDIAN RESIDENT AGE AT 40.0 YEARS. THE POPULATION DECREASED -0.7% SINCE 2010, BUT OVERALL THE POPULATION HAS STAYED CONSISTENT OVER THE LAST DECADE. |
| PART VI, LINE 5: | SIBLEY MEDICAL CENTER PROVIDES COMMUNITY EDUCATION AND WORKS WITH HEALTH CARE PROVIDERS IN MEEKER, MCLEOD AND SIBLEY COUNTIES TO IMPROVE THE HEALTH OF OUR COMMUNITY. |
| PART VI, LINE 6: | SIBLEY MEDICAL CENTER IS A SUBSIDIARY OF RIDGEVIEW MEDICAL CENTER, A 109-BED ACUTE CARE HOSPITAL IN WACONIA, MINNESOTA THAT PROVIDES HEALTHCARE SERVICES TO THE RESIDENTS OF THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MINNESOTA. RIDGEVIEW MEDICAL CENTER'S OTHER SUBSIDIARIES INCLUDE:1. RIDGEVIEW CLINICS PROVIDES OUTPATIENT HEALTHCARE SERVICES FROM VARIOUS CLINIC LOCATIONS THROUGHOUT THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MINNESOTA.2. SIBLEY MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL IN ARLINGTON, MINNESOTA.3. CHASKA PLAZA SURGERY CENTER OPERATES AN AMBULATORY SURGICAL CENTER. CHASKA PLAZA SURGERY CENTER IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER OWNS A 51% INTEREST.4. MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER PROVIDES CARDIOLOGY SERVICES. THE HEART INSTITUTE IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER HOLDS A 50% INTEREST.5. WACONIA BUILDING INVESTMENTS OWNS A MEDICAL OFFICE BUILDING ON RIDGEVIEW MEDICAL CENTER'S CAMPUS.6. RIDGEVIEW REAL ESTATE LLC HOLDS THE LAND LEASE FOR WACONIA BUILDING INVESTMENTS.7. RIDGEVIEW COMMUNITY NETWORK LLC OPERATES AN ACCOUNTABLE CARE ORGANIZATION.8. RIDGEVIEW INSURANCE COMPANY OPERATES A CAPTIVE INSURANCE COMPANY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER.9. RIDGEVIEW FOUNDATION OPERATES FOR THE EXCLUSIVE BENEFIT OF RIDGEVIEW MEDICAL CENTER. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (3 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TODD SANDBERG | ||||||||||||||
| RSMC ADMINISTRATOR | $0 | $172,673 | $0 | $15,000 | $0 | $16,126 | $0 | $8,093 | $0 | $12,700 | $0 | $224,592 | $0 | $0 |
| ROBERT STEVENS | ||||||||||||||
| PRESIDENT / CEO | $0 | $438,935 | $0 | $0 | $0 | $40,654 | $0 | $9,990 | $0 | $11,170 | $0 | $500,749 | $0 | $0 |
| GORDON GABLENZ | ||||||||||||||
| CFO & CIO | $0 | $300,079 | $0 | $15,000 | $0 | $52,546 | $0 | $10,600 | $0 | $20,010 | $0 | $398,235 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 3 | FormAndLineReferenceDesc |
| Explanation | THE ADMINISTRATOR'S COMPENSATION IS DETERMINED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. THE FOLLOWING WERE USED BY RIDGEVIEW MEDICAL CENTER TO DETERMINE THE ADMINISTRATOR'S COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | RIDGEVIEW MEDICAL CENTER SHALL BE THE SOLE MEMBER OF THE CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | RIDGEVIEW MEDICAL CENTER, AS THE MEMBER, MUST APPROVE ALL NEW DIRECTORS. AT ALL TIMES THERE WILL ALWAYS BE A DIRECTOR WHO IS APPOINTED BY THE MEMBER AND WHO SITS ON THE BOARD OF DIRECTORS OF THE MEMBER. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE BOARD OF DIRECTORS WILL CARRY OUT THE DUTIES NORMALLY ASSOCIATED WITH A NONPROFIT HOSPITAL BOARD OF DIRECTORS, SUBJECT TO THE RESERVED POWERS OF THE MEMBER AND THE CITY BELOW. THE MEMBER RESERVED AUTHORITY WITH REGARD TO THE MATTERS LISTED BELOW, SUBJECT TO THE RESERVED POWERS OF THE CITY INCLUDED THEREAFTER. THE MEMBER WILL LOOK TO THE BOARD TO MAKE RECOMMENDATIONS ON DECISIONS ON MATTERS LISTED BELOW, BUT THE MEMBER IS NOT REQUIRED TO ACCEPT SUCH RECOMMENDATIONS, AND THE MEMBER MAY TAKE ACTION ON ITS OWN IN SUCH AREAS, SUBJECT TO THE CITY'S RESERVED POWERS. THE MEMBER'S APPROVAL WILL BE REQUIRED FOR ANY ACTION PROPOSED BY THE BOARD IN THESE AREAS: (A) FINAL APPOINTMENT OF BOARD MEMBERS (B) ISSUANCE OF DEBT BY THE CORPORATION (C) SALE OF SUBSTANTIAL ASSETS OF THE CORPORATION (D) CHANGES IN THE CORPORATION'S ARTICLES OF INCORPORATION AND BYLAWS (E) ESTABLISHMENT OF ANOTHER MEMBER RELATIONSHIP BY THE CORPORATION OR ANOTHER FORM OF AFFILIATION (F) STRATEGIC PLAN FOR THE CORPORATION (G) OPERATING AND CAPITAL BUDGETS OF THE CORPORATION (H) UNBUDGETED TOTAL ANNUAL CAPITAL EXPENDITURES (I) AUDIT AND COMPLIANCE PROGRAMS (J) ACCREDITATION PROGRAMS (K) GROUP EMPLOYEE BENEFITS (L) MANAGING THE CORPORATION'S CASH AND INVESTMENTS (THE MEMBER MAY MOVE FUNDS BETWEEN THE ORGANIZATIONS FREELY, SUBJECT TO BOND COVENANT OR TRUSTEE REQUIREMENTS) (M) THIRD PARTY PAYER CONTRACTING (N) INSURANCE (O) INFORMATION SYSTEM DESIGN AND IMPLEMENTATION (P) GROUP PURCHASING THE CITY'S APPROVAL WILL BE REQUIRED FOR THE DECISIONS OF THE BOARD IN THE FOLLOWING AREAS: (A) SALE OF ALL OR SUBSTANTIALLY ALL OF THE CORPORATION'S ASSETS (B) SALE OF ASSETS ABOVE THRESHOLDS ALLOWED BY BOND COVENANTS (C) ISSUANCE OF DEBT WHICH WOULD OBLIGATE THE CORPORATION IN EXCESS OF LEVELS ALLOWED BY BOND COVENANTS (D) CHANGES TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS |
| FORM 990, PART VI, SECTION B, LINE 11 | THE CFO REVIEWED THE FORM 990 AND PROVIDED A COPY OF THE FORM 990 TO THE BOARD OF DIRECTORS PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE BOARD MEMBERS ANNUALLY REVIEW AND SIGN THE STATEMENTS FOR POTENTIAL CONFLICTS OF INTEREST POLICY. EACH MEMBER IS EXPECTED TO DISCLOSE ANY CONFLICT OF INTEREST THAT MAY ARISE DURING THE YEAR. IF IT IS DETERMINED THAT A CONFLICT OF INTEREST EXISTS, THE SITUATION WILL BE EXAMINED AND HANDLED APPROPRIATELY BY THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 15 | ALL COMPENSATION IS DETERMINED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| RIDGEVIEW FOUNDATION | |||||||||||
| 500 SOUTH MAPLE STREET | WACONIA | MN | 55387 | 411328097 | RAISING FUNDS FOR RIDGEVIEW MEDICAL CENTER | MN | 501(3)(C) | LINE 7 | RIDGEVIEW MEDICAL CENTER | 0 | |
| RIDGEVIEW MEDICAL CENTER | |||||||||||
| 500 SOUTH MAPLE STREET | WACONIA | MN | 55387 | 311667875 | HEALTH CARE SERVICES | MN | 501(3)(C) | LINE 3 | 0 | N/A | |
| RIDGEVIEW INSURANCE COMPANY | |||||||||||
| 60 E SOUTH TEMPLE STE 1800 | SALT LAKE CITY | UT | 84111 | 454109041 | CAPTIVE INSURANCE COMPANY | UT | 501(3)(C) | LINE 11A, I | RIDGEVIEW MEDICAL CENTER | 0 | |
| RIDGEVIEW CLINICS | |||||||||||
| 500 SOUTH MAPLE STREET | WACONIA | MN | 55387 | 411651783 | HEALTH CARE SERVICES | MN | 501(3)(C) | LINE 3 | RIDGEVIEW MEDICAL CENTER | 0 | |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|
| MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER LLC | |||||||
| 500 S MAPLE ST | WACONIA | MN | 55387 | 205785920 | CARDIOLOGY SERVICES | MN | N/A |
| CHASKA PLAZA SURGERY CENTER | |||||||
| 3000 HUNDERTMARK RD | CHASKA | MN | 55318 | 450975783 | SURGERY SERVICES | MN | N/A |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|
| EXECUTIVE HEALTH MANAGEMENT SERVICES INC | |||||||||
| 500 SOUTH MAPLE STREET | WACONIA | MN | 55387 | 411760239 | MANAGEMENT SERVICES | MN | N/A | C | 0 |
| CHARITABLE REMAINDER UNITRUST (1) | |||||||||
| CHARITABLE TRUST | MN | 0 | |||||||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | Yes (1) | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | Yes (1) | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |