2016-11-15T15:44:36-06:00 2015-12-31 420714325 RSM US LLP 801 NICOLLET MALL SUITE 1100 MINNEAPOLIS MN 55402 990 2015-01-01 411865874 GRAND ITASCA CLINIC AND HOSPITAL GRAN 2183265000 1601 GOLF COURSE ROAD GRAND RAPIDS MN 55744 MIKE YOUSO PRESIDENT & CEO 2183265000 2016-11-08 1 TODD A JACKSON P00092672 6123324300 2015 2017-02-10 21:41:12Z MICHAEL YOUSO 1601 GOLF COURSE ROAD GRAND RAPIDS MN 55744 76063609 0 X WWW.GRANDITASCA.ORG X 1997 MN PATIENT-CENTERED EXCELLENCE 11 9 725 97 89353 -15476 212866 200569 74578952 74970564 27370 30351 140768 841987 74959956 76043471 0 0 0 0 49156955 50679378 0 0 385145 30627840 33985828 79784795 84665206 -4824839 -8621735 82047950 77400313 49229106 47963640 32818844 29436673 X PROVIDE QUALITY, ACCESSIBLE, AND VALUABLE HEALTH CARE SERVICES VIA A HOSPITAL, HOME HEALTH AGENCY, AND CLINIC TO THE SURROUNDING RURAL COMMUNITY. 0 0 68837307 75728803 GRAND ITASCA CLINIC AND HOSPITAL (GICH) IS AN INTEGRATED MULTI-SPECIALTY CLINIC AND ACUTE/SURGICAL HOSPITAL. THE FACILITY IS LICENSED FOR 64 BEDS WHICH ARE COMPRISED OF 48 MEDICAL BEDS, 10 INTENSIVE CARE BEDS AND 6 OB BEDS. IN ADDITION TO PROVIDING TRADITIONAL HOSPITAL SERVICES, THE FACILITY HAS FOUR SURGERY SUITES, A 24-HOUR EMERGENCY DEPARTMENT, OUTPATIENT MENTAL HEALTH SERVICES, OUTPATIENT REHABILITATION SERVICES, AND OUTPATIENT CLINIC SERVICES. THE FACILITY EMPLOYS APPROXIMATELY 609 PEOPLE INCLUDING 59 HEALTHCARE PROVIDERS.THE FACILITY SERVED APPROXIMATELY 1,685 INPATIENTS AND APPROXIMATELY 222,868 OUTPATIENT ENCOUNTERS INCLUDING CLINIC, EMERGENCY ROOM, OUTPATIENT IMAGING AND OUTPATIENT SURGICAL PROCEDURE. GRAND ITASCA SERVES THE PATIENT REGARDLESS OF THE PERSON'S ABILITY TO PAY. DURING THE 2015 CALENDAR YEAR, THE FACILITY PROVIDED $147,127 OF CHARITY CARE, $289,418 DISCOUNT TO THE UNINSURED AND ABSORBED $10,883,624 OF UNPAID MEDICARE AND MEDICAID COSTS. GRAND ITASCA CLINIC AND HOSPITAL ALSO PROVIDES OTHER SUPPORT TO THE COMMUNITY THROUGH CASH AND IN-KIND DONATIONS THAT TOTALED $13,646 IN 2015 CALENDAR YEAR. IN ADDITION, GRAND ITASCA PROVIDED HEALTHCARE SUPPORT SERVICES OF $16,787 INCLUDING ASK-A-NURSE AND PATIENT TRANSPORTATION. GRAND ITASCA ALSO PAID $1,315,315 IN PAYMENTS FOR MINNESOTA CARE TAX AND MEDICAID SURCHARGES, WHICH WERE USED TO FUND CARE FOR THE INDIGENT AND UNDERINSURED. 68837307 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 37 0 1 725 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 MN X COREY SMITH 2189991703 1601 GOLF COURSE ROAD GRAND RAPIDS MN 55744 ELIZABETH MISKOVICH CHAIR 1.00 X X 0 0 0 COLLEEN NARDONE VICE CHAIR 1.00 X X 0 0 0 MARY KOSAK SECRETARY 1.00 X X 0 0 0 SHELLY STERRE TREASURER 1.00 X X 0 0 0 RON IANNELLI DIRECTOR 1.00 X 0 0 0 JANICE M ROURK DIRECTOR/PEDIATRIC MD 40.00 1.00 X 144714 0 22389 JAMISON L HARKER MD DIRECTOR/INTERNAL MEDICINE 40.00 1.00 X 225852 0 33453 MIKE IVES DIRECTOR 1.00 X 0 0 0 CHARLES KAMPEN DIRECTOR 1.00 X 0 0 0 KENT KOERBITZ DIRECTOR 1.00 X 0 0 0 DALE ADAMS DIRECTOR 1.00 X 0 0 0 MARVA JEAN HUTCHENS DIRECTOR 1.00 X 0 0 0 JOSH SKELTON DIRECTOR 1.00 X 0 0 0 BARB UNGER DIRECTOR 1.00 X 0 0 0 MICHAEL J YOUSO PRESIDENT & CEO 40.00 X 325115 0 33453 DEBRA M NYQUIST CHIEF MEDICAL OFFICER 40.00 X 327162 0 22389 SARAH J GUSTAFSON VP FINANCE 40.00 X 52264 0 1532 EDWARD A TUSA VP FINANCE 40.00 X 108974 0 19299 TROY D ERICKSON ORTHOPEDIC SURGEON 40.00 X 631963 0 33453 DEREK A BEYER OB/GYN MD CLINIC 40.00 X 403869 0 33453 KURT W POSSAI ORTHOPEDIC SURGEION 40.00 X 390897 0 19299 KEVIN P GILDNER OB/GYN MD CLINIC 40.00 X 363860 0 29889 RYAN T NOVAK UROLOGIST MD 40.00 X 537732 0 33453 3512402 0 282062 69 0 1 0 ALLINA HEALTH SYSTEM NW 7710 PO BOX 9383 MINNEAPOLIS MN 55440 IT/LAB SERVICES 1834164 ARAMARK 26605 NETWORK PLACE CHICAGO IL 60673 LAUNDRY SERVICES 346886 SOJOURN PATHOLOGY SERVICES 35328 COUNTY RD 63 COHASSET MN 55721 MEDICAL SERVICES 336666 INFOR INC NW 7418 PO BOX 1450 MINNEAPOLIS MN 55485 IT SERVICES 280569 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 ACCOUNTING SERVICES 253148 14 51434 149135 200569 PATIENTS AND RESIDENT SERVICES 621110 70561705 70561705 MEANINGFUL USE REVENUE 621110 1483846 1483846 OTHER REVENUE 621110 1388881 1388881 REIMBURSED EXPENSES 621110 771261 771261 PHARMACY REVENUE 621110 764871 675518 89353 74970564 15489 15489 35000 20138 14862 14862 14862 CDI PARTNERSHIP REVENUE 621110 758239 758239 PURCHASE DISCOUNTS 621110 60260 60260 CDI AMORTIZATION GAIN 621110 23488 23488 841987 76043471 75662938 89353 90611 1384787 1116239 262013 6535 39998726 32241888 7568089 188749 2374876 1914323 449346 11207 3791408 3056151 717366 17891 3129581 2522670 592143 14768 118797 95759 22477 561 177232 142862 33534 836 1911 1911 319822 257800 60513 1509 834592 672742 157912 3938 2599463 2095356 491840 12267 122326 98604 23145 577 1605892 1294466 303848 7578 5065798 4083402 958491 23905 612885 494030 115963 2892 REPAIRS & MAINT 13163381 10610644 2490620 62117 NON PHY FEES 3315215 2672305 627266 15644 PROVISION FOR BAD DEBTS 3047445 3047445 SUPPLIES 1045929 843095 197898 4936 1955140 1577526 368379 9235 84665206 68837307 15442754 385145 3851854 1497039 5058371 5079043 80293 13107057 10262081 133226 128183 1065629 1243676 953347 1053021 74376833 35831089 40817934 38545744 9229749 10918663 7964009 8459344 82047950 77400313 6170203 4836509 427247 636400 31585243 31046029 11046413 11444702 49229106 47963640 X 32610833 29243098 208011 193575 32818844 29436673 82047950 77400313 X -8621735 -55152 467433 4827283 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1911 1911 0 PART II-B, LINE 1: GICH PAYS DUES TO THE MINNESOTA HOSPITAL ASSOCIATION (MHA), A PORTION OF WHICH RELATES TO LOBBYING ACTIVITIES. FOR CALENDAR YEAR 2015, MHA HAS DETERMINED THAT 3.7% OR $1,911 OF ITS MEMBERSHIP DUES WERE USED FOR LOBBYING PURPOSES. 607331 607331 45030057 18477352 26552705 28167531 17233387 10934144 571914 120350 451564 38545744 MUTUAL FUNDS 5579198 C CERT OF DEPOSIT (TIME DEPOSITS) 222623 C CERT OF DEPOSIT (MARKETABLE SECURITIES) 2397794 C DEFERRED COMPENSATION INVESTMENTS 2719048 C 10918663 DEFERRED FINANCING COSTS 762528 ASSETS LIMITED TO USE 6793495 CHARITABLE REMAINDER TRUST 193575 OTHER ASSETS 377272 CDI CONTROLLING INTEREST 332474 8459344 OTHER ACCRUALS 335965 POST RETIREMENT BENEFIT 3111663 SELF INSURED WORKER'S COMP 910730 CURRENT PORTION OF LONG TERM DEBT 1888472 THIRD PARTY PAYOR SETTLEMENTS 2478824 DEFERRED COMPENSATION OBLIGATIONS 2719048 11444702 X PART X, LINE 2: THE CORPORATION AND THE FOUNDATION HAVE REVIEWED THEIR TAX POSITIONS FOR ALL OPEN YEARS AND HAVE CONCLUDED THAT NO MATERIAL LIABILITIES EXIST AS OF DECEMBER 31, 2015. GENERALLY, THE CORPORATION AND THE FOUNDATION ARE NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL, STATE OR LOCAL TAX AUTHORITIES FOR YEARS PRIOR TO THE FISCAL YEAR ENDED DECEMBER 31, 2012. 1 1 1 X 1 X 1 1 1 0 1 1 656985 0 656985 0.00800 18616368 13286410 5329958 0.06530 19273353 13286410 5986943 0.07330 16788 16788 0.00020 8000 8000 0.00010 13647 13647 0.00020 38435 38435 0.00050 19311788 13286410 6025378 0.07380 1 3047445 761861 16894950 21181742 -4286792 X 1 1 1 CDI GRAND RAPIDS LLC PROVIDE MRI, DIAGNOSTIC INJECTION AND PAIN MANAGEMENT SERVICES 0.55000 0.00000 0.00000 1 1 GRAND ITASCA CLINIC AND HOSPITAL 1601 GOLF COURSE ROAD GRAND RAPIDS MN 55744 X X X GRAND ITASCA CLINIC AND HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X GRANDITASCA.ORG X 1 15 1 GRANDITASCA.ORG (UNDER NEWS & EVENTS) 0 0 1 X 150.000000000000 300.000000000000 X X X 1 1 X X X X 1 X GRANDITASCA.ORG X GRANDITASCA.ORG X X X X X 1 X X 1 X X X X X 1 X 0 0 GRAND ITASCA CLINIC AND HOSPITAL PART V, SECTION B, LINE 5: GRAND ITASCA CLINIC AND HOSPITAL CONDUCTED THE COMMUNITY HEALTH NEEDS ASSESSMENT BY GATHERING INPUT FROM COMMUNITY PROFESSIONALS INCLUDING REPRESENTATION FROM THE COUNTY PUBLIC NURSE, YMCA, UNITED WAY, CITY OFFICIALS, LOCAL HEALTHCARE PROFESSIONALS AND REPRESENTATION FROM THE GENERAL PUBLIC. THIS INFORMATION WAS GATHERED DURING SESSIONS FACILITATED BY AN INDEPENDENT PARTY. GRAND ITASCA CLINIC AND HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL ADOPTED AN IMPLEMENTATION PLAN IN 2013 THAT WAS IMPLEMENTED IN 2014 TO SUSTAIN AND DEVELOP COMMUNITY BENEFIT PROGRAMS THAT 1) ADDRESS PRIORITIZED NEEDS FROM THE 2012-2013 CHNA AND 2) RESPOND TO ADDITIONAL COMMUNITY HEALTH NEEDS. GRAND ITASCA HAS ELECTED TO TARGET THE FOLLOWING THREE IDENTIFIED HEALTH NEEDS IN THE COMMUNITY:1 - PREVENTION OF CHRONIC DISEASE INCLUDING HEART DISEASE, STROKE, AND CANCER.2 - MANAGEMENT OF CHRONIC DISEASE INCLUDING HEART DISEASE, STROKE, AND CANCER.3 - PREVENTION AND REDUCTION IN ALCOHOL AND DRUG USE IN ITASCA COUNTY.FOR EACH OF THE PRIORITY NEEDS IDENTIFIED ABOVE, GRAND ITASCA CLINIC AND HOSPITAL WILL WORK WITH COMMUNITY PARTNERS TO:- STRENGHTEN COMMUNITY CONNECTIONS, OUTREACH AND SUPPORT FOR INITIATIVES IDENTIFIED ABOVE- REDUCE RISKY BEHAVIORS- DEVELOP MEASURABLE GOALS AND OBJECTIVES UTILIZING BIOMETRIC SCREENING AND RESCREENING DATA COLLECTED FROM HEALTHY COMMUNITIES PARTNERSHIP PARTICIPANTS- DEVELOP DETAILED WORK PLANS.NEEDS NOT BEING ADDRESSED - WHILE IDENTIFIED BY THE STEERING COMMITTEE AS PROBABLE HEALTH NEEDS IN ITASCA COUNTY, GRAND ITASCA FEELS THAT THESE NEEDS REQUIRE FURTHER EVAULATION.- TRANSPORTATION: ALTHOUGH A TOPIC OF DISCUSSION AT BOTH THE STEERING COMMITTEE AND COMMITTEE MEETINGS, TRANSPORTATION DATA IN RURAL AREAS IS NOT READILY AVAILABLE; THUS, MAKING IT DIFFICULT TO PINPOINT THE NUMBER AND TYPES OF HEALTH CARE TRANSPORTATION THAT MAY BE NEEDED. THE STEERING COMMITTEE CONCLUDED THAT THIS ISSUE WOULD REQUIRE FURTHER RESEARCH AND BETTER SUITED TO A POINT OF DISCUSSION AT THE CITY AND COUNTY GOVERNMENT LEVELS.- REDUCING UNINSURED RATE IN ITASCA COUNTY: PROVIDING CONVENIENT ACCESS TO NECESSARY MEDICAL CARE REGARDLESS OF ONE'S ABILITY TO PAY IS IMPORTANT TO GRAND ITASCA. CURRENTLY GRAND ITASCA ASSISTS THOSE PERSONS WITH INSURANCE AND FINANCIAL COUNSELING ON AS-NEEDED BASIS. DUE TO THE EXPANSION OF AFFORDABLE INSURANCE OPTIONS THAT WILL BECOME AVAILABLE TO ALL MINNESOTA RESIDENTS IN LATE 2013 THE UNINSURED RATE IN ITASCA COUNTY IS EXPECTED TO GO DOWN. - MENTAL HEALTH MANAGEMENT: SEVERAL MENTAL HEALTH ISSUES WERE IDENTIFIED AS PART OF THE MN STUDENT SURVEY BUT BECAUSE OF THE LIMITED DEMOGRAPHIC SEGMENT OF RESPONDENTS, ADDITIONAL INFORMATION IS NEEDED TO CLARIFY THE EXTENT OF THE NEED. TO OBTAIN THIS NECESSARY INFORMATION, ITASCA COUNTY CONDUCTED A SERIES OF COMMUNITY CONVERSATIONS ON MENTAL HEALTH IN FALL OF 2013. A REPRESENTATIVE OF THE GRAND ITASCA BOARD IS CURRENTLY PARTICIPATING IN THE PROCESS. GRAND ITASCA CLINIC AND HOSPITAL PART V, SECTION B, LINE 18D: PRE-ADMISSION DEPOSIT, VERIFICATION OF INFORMATION, PAYMENT ARRANGEMENTS GRAND ITASCA CLINIC AND HOSPITAL PART V, SECTION B, LINE 20E: PATIENT RECEIVES A SERIES OF LETTERS INDICATING ACTIONS TO BE TAKEN IF PAYMENT ARRANGEMENTS ARE NOT MADE WITH THE FACILITY. 1 1 - GRAND ITASCA PROFESSIONAL BUILDING 111 SE 3RD STREET GRAND RAPIDS MN 55744 VARIOUS OUTPATIENT & BUSINESS SERVICES PART I, LINE 7: THE COSTING METHOD USED IS TO UTILIZE THE COST REPORT TO CAPTURE THE COST TO CHARGE RATIO. WE THEN COST OUT TOTAL BAD DEBT REPORTED AS CHARGES TO THE COST OF PROVIDING THOSE SERVICES. FROM REVIEW OF THE NUMBER OF APPLICATIONS DENIED FOR INSUFFICIENT INFORMATION WE ESTIMATE 25% OF BAD DEBT IS RELATED TO INDIVIDUALS WHO WOULD QUALIFY FOR CHARITY CARE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,047,445. PART II, COMMUNITY BUILDING ACTIVITIES: GRAND ITASCA'S COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES BY PROVIDING INNOVATIVE AND ADVANCED MEDICAL SERVICES, WITH HIGH-QUALITY, SEAMLESS PATIENT CARE IN MIND. GRAND ITASCA'S INTERPRETATION AND ED PATIENT TAXI CAB SERVICES ALLOW FOR THE CARE OF EACH AND EVERY PATIENT, NO MATTER THE INITIAL BARRIERS OR HARDSHIPS THAT MAY EXIST. THE NURSE ON-LINE PROGRAM, BY PROVIDING A 24-HOUR MEDICAL ADVICE HOTLINE, EMPOWERS PATIENTS TO MAKE EDUCATED DECISIONS ABOUT THEIR MEDICAL TREATMENT. TRIAGE CAN BE COMPLETED PRIOR TO A PATIENT'S ARRIVAL, ALLOWING MEDICAL RESOURCES TO BE ALLOCATED MORE EFFICIENTLY AND EFFECTIVELY. PART III, LINE 2: AN ESTIMATE FOR BAD DEBT IS CALCULATED MONTHLY BASED ON AGED A/R DUE FROM PATIENTS TO INSURE WE HAVE AN APPROPRIATE ALLOWANCE FOR UNCOLLECTABLE ACCOUNTS. PART III, LINE 3: THE COSTING METHOD USED IS TO UTILIZE THE COST REPORT TO CAPTURE THE COST TO CHARGE RATIO. WE THEN COST OUT TOTAL BAD DEBT REPORTED AS CHARGES TO THE COST OF PROVIDING THOSE SERVICES. FROM REVIEW OF THE NUMBER OF APPLICATIONS DENIED FOR INSUFFICIENT INFORMATION WE ESTIMATE 25% OF BAD DEBT IS RELATED TO INDIVIDUALS WHO WOULD QUALIFY FOR CHARITY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE, WHERE A THIRD-PARTY PAYOR IS RESPONSIBLE FOR PAYING THE AMOUNT, ARE CARRIED AT A NET AMOUNT DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICES PROVIDED, ADJUSTED BY AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS.PATIENT ACCOUNTS RECEIVABLE DUE DIRECTLY FROM THE PATIENT ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICES PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY USING HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS, AND BY CONSIDERING THE PATIENT'S FINANCIAL HISTORY AND CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. PATIENT ACCOUNTS RECEIVABLE ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 8: THE SHORTFALL IS THE COST OF SERVICES PROVIDED TO THE MEDICARE POPULATION IN THE COMMUNITY FOR WHICH WE DO NOT RECOUP ANY PAYMENTS FROM THE PATIENTS. THE COSTING METHODOLOGY IS TO UTLIZE THE COST TO CHARGE RATIO AS DETERMINED BY THE COST REPORT FOR THAT PERIOD. PART III, LINE 9B: ACCORDING TO ITS FINANCIAL POLICY, GRAND ITASCA CLINIC & HOSPITAL HOLDS RESPONSIBILITY FOR INFORMING ALL PATIENTS OF THEIR FINANCIAL OBLIGATIONS FOR SERVICES RECEIVED AND RESERVES THE RIGHT TO HOLD THE PATIENT OR HIS LEGAL REPRESENTATIVE ULTIMATELY RESPONSIBLE FOR ALL CHARGES INCURRED ONCE ANY COMMUNITY CARE DISCOUNT HAS BEEN ESTABLISHED BY THE ORGANIZATION. PATIENTS MAY BE REQUIRED TO MAKE PRE-ADMISSION DEPOSITS, PAY PRIOR OUTSTANDING ACCOUNTS IN FULL BEFORE RECEIVING ADDITIONAL SERVICES, OR ENTER INTO A PAYMENT ARRANGEMENT WITH GRAND ITASCA. IF DEEMED APPROPRIATE, GRAND ITASCA MAY REFER ACCOUNTS UNABLE TO BE COLLECTED IN-HOUSE TO A COLLECTION AGENCY, MAGISTRATE, OR ATTORNEY FOR FURTHER ACTION; OR TAKE LEGAL ACTION TO COLLECT ANY UNPAID BALANCES. PART VI, LINE 2: GRAND ITASCA REVIEWS APPLICABLE STATE AND COUNTY SURVEYS PERFORMED BY OTHER AGENCIES TO ASSESS THE NEEDS OF THE COMMUNITY. GRAND ITASCA WORKS WITH THESE AGENCIES TO PROVIDE THESE SERVICES WITHIN THE SCOPE OF THE MEDICAL FACILITY. PART VI, LINE 3: GRAND ITASCA HAS FINANCIAL ADVOCATES WORKING WITH UNINSURED PATIENTS TO ASSIST THEM IN COMPLETING APPLICATIONS FOR VARIOUS PROGRAMS THAT MAY PROVIDE THEM COVERAGE FOR MEDICAL SERVICES. PART VI, LINE 4: GRAND ITASCA SERVES THE PEOPLE OF GRAND RAPIDS AND THE SURROUNDING COMMUNITIES THROUGHOUT ITASCA COUNTY. THESE COMMUNITIES CONSIST PRIMARILY OF CAUCASIAN RACE, WITH GROWING POPULATIONS OF AMERICAN INDIAN, HISPANIC, AND AFRICAN AMERICAN CITIZENS PART VI, LINE 5: GRAND ITASCA PROMOTES HEALTH IN THE COMMUNITY BY SUPPORTING THE LOCAL FREE CLINIC, THROUGH THE PROVISION OF MEDICAL SUPPLIES, BASIC LAB TESTS AND BASIC X-RAYS TO THE PATIENTS OF THIS CLINIC AT NO CHARGE. GRAND ITASCA ALSO WORKS WITH A COMMUNITY COALITION TO DETERMINE THE HEALTH NEEDS OF THE COMMUNITY SERVICED BY GRAND ITASCA CLINIC & HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES MN X X X 0 0 0 0 0 0 0 0 0 JANICE M ROURK DIRECTOR/PEDIATRIC MD 144714 0 0 0 0 0 6819 0 16533 0 168066 0 0 0 JAMISON L HARKER MD DIRECTOR/INTERNAL MEDICINE 225852 0 0 0 0 0 14156 0 24386 0 264394 0 0 0 MICHAEL J YOUSO PRESIDENT & CEO 325115 0 0 0 0 0 15847 0 24871 0 365833 0 0 0 DEBRA M NYQUIST CHIEF MEDICAL OFFICER 327162 0 0 0 0 0 15847 0 17376 0 360385 0 0 0 TROY D ERICKSON ORTHOPEDIC SURGEON 631963 0 0 0 0 0 15847 0 23436 0 671246 0 0 0 DEREK A BEYER OB/GYN MD CLINIC 403869 0 0 0 0 0 11872 0 22680 0 438421 0 0 0 KURT W POSSAI ORTHOPEDIC SURGEION 390897 0 0 0 0 0 15847 0 13750 0 420494 0 0 0 KEVIN P GILDNER OB/GYN MD CLINIC 363860 0 0 0 0 0 15847 0 20846 0 400553 0 0 0 RYAN T NOVAK UROLOGIST MD 537732 0 0 0 0 0 15847 0 24785 0 578364 0 0 0 RYAN T NOVAK TOP 5 HIGHLY COMPENSATED EMPLOYEE COMPENSATION PACKAGE X 90000 22978 0 1 1 TROY D ERICKSON TOP 5 HIGHLY COMPENSATED EMPLOYEE COMPENSATION PACKAGE X 51000 17158 0 1 1 DEREK A BEYER TOP 5 HIGHLY COMPENSATED EMPLOYEE COMPENSATION PACKAGE X 50000 22503 0 1 1 KURT W POSSAI TOP 5 HIGHLY COMPENSATED EMPLOYEE COMPENSATION PACKAGE X 75000 53848 0 1 1 KEVIN P GILDNER TOP 5 HIGHLY COMPENSATED EMPLOYEE COMPENSATION PACKAGE X 35000 16739 0 1 1 133226 SHANNON HARKER WIFE OF DIRECTOR; PEDIATRIC MD CLINIC 169799 DR. SHANNON HARKER IS A COMPENSATED DOCTOR OF GICH. 0 FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED BY THE CONTROLLER AND A COPY IS PRESENTED TO THE FINANCE COMMITTEE AND BOARD OF DIRECTORS FOR APPROVAL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS SIGN THE CONFLICT OF INTEREST POLICY ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS DETERMINED BY ASSESSING THE MARKET THROUGH THE USE OF SURVEYS AND STUDIES AND DETERMINING PAY RATES AND RANGES FROM THE RESULTS OF THE ASSESSMENT. THE CEO COMPENSATION PACKAGE IS SUMMARIZED IN AN EMPLOYMENT AGREEMENT THAT IS APPROVED BY THE BOARD. THE COMPENSATION PACKAGE IS BASED UPON MARKET FOR THE POSITION. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST FOR THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN SECTION 6104(D). FORM 990, PART XI, LINE 9: POST RETIREMENT BENEFITS OBLIGATION ADJUSTMENT 4,704,627. NON-CASH CONTRIBUTION FROM GRAND ITASCA FOUNDATION NET ASSETS RELEASED FROM RESTRICTIONS USED FOR PROPERTY & EQUIPMENT 122,656. FORM 990, PART VI, SECTION B, LINE 16A GRAND ITASCA THOROUGHLY EVALUATED THE PARTICIPATION IN THE CDI JOINT VENTURE. THIS EVALUATION INCLUDED REVIEW BY ATTORNEYS AND OTHER THIRD PARTY CONSULTANTS. GRAND ITASCA FOUNDATION 1601 GOLF COURSE ROAD GRAND RAPIDS MN 55744 411560554 FINANCIAL SUPPORT OF GRAND ITASCA CLINIC & HOSPITAL MN 501(C)(3) 11(F) GRAND ITASCA CLINIC & HOSPITAL 1 CDI GRAND RAPIDS LLC 1601 GOLF COURSE RD GRAND RAPIDS MN 55744 453783014 PROVIDE IN-HOUSE MRI AND DTI SERVICES MN GRAND ITASCA CLINIC & HOSPITAL RELATED 878216 906199 1 1 0.55000 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 GRAND ITASCA FOUNDATION C 51434 ACTUAL AMOUNT