2015-11-10T13:12:59-06:00 2014-12-31 990 2014-01-01 411906820 MAYO CLINIC HEALTH SYSTEM-LAKE CITY MAYO 5075381297 500 WEST GRANT STREET LAKE CITY MN 55041 JAMES J TARASOVITCH REGION CFO 5073852646 2015-11-10 2014 2016-02-25 16:41:14Z DAVID C AGERTER MD 500 WEST GRANT STREET LAKE CITY MN 55041 47275038 0 5983 X WWW.MAYOCLINICHEALTHSYSTEM.ORG X 1998 MN OPERATION OF A HOSPITAL, FOUR CLINICS AND A NURSING HOME. 8 4 335 149 0 0 495412 453408 40110493 45891970 -17620 90723 143056 141166 40731341 46577267 7601 9718 0 0 18433220 17424644 0 0 39139 22910592 24773339 41351413 42207701 -620072 4369566 29971969 34755493 3683936 4100894 26288033 30654599 X TO INSPIRE HOPE AND CONTRIBUTE TO HEALTH AND WELL-BEING BY PROVIDING THE BEST CARE TO EVERY PATIENT THROUGH INTEGRATED CLINICAL PRACTICE, EDUCATION, AND RESEARCH. 0 0 26100061 38664973 PATIENT SERVICES (HOSPITAL & CLINICS) - SEE SCHEDULE O:MAYO CLINIC HEALTH SYSTEM - LAKE CITY (MCHS-LAKE CITY) IS A MEMBER OF THE MAYO CLINIC HEALTH SYSTEM. MAYO CLINIC HEALTH SYSTEM IS A FAMILY OF CLINICS, HOSPITALS AND HEALTH CARE FACILITIES SERVING COMMUNITIES IN MINNESOTA, IOWA, WISCONSIN AND GEORGIA. AS PART OF MAYO CLINIC, THE HEALTH SYSTEM OFFERS CARE DESIGNED FOR THE WHOLE BODY CLOSE TO THE PATIENT'S HOME, WHEN THEY NEED IT. A MULTIDISCIPLINARY TEAM OF EXPERTS HAS READY ACCESS TO KNOWLEDGE, RESOURCES, AND EXPERTISE OF MAYO CLINIC AND COLLABORATES ON PROVIDING EXACTLY THE CARE THE PATIENT NEEDS. MAYO CLINIC HEALTH SYSTEM SITES EMPLOY APPROXIMATELY 1,000 PHYSICIANS AND 15,000 ALLIED HEALTH STAFF. IN ADDITION, MAYO CLINIC PHYSICIANS FROM MULTIPLE SPECIALTIES REGULARLY SEE PATIENTS AT HEALTH SYSTEM FACILITIES. BESIDES HAVING HEALTH CARE FACILITIES IN NEARLY 70 COMMUNITIES, MAYO CLINIC HEALTH SYSTEM INCLUDES 19 OWNED HOSPITALS, FIVE OWNED NURSING HOMES, PHYSICIAN SERVICE AGREEMENTS WITH ONE ADDITIONAL HOSPITAL, AND CONTRACT MANAGEMENT AGREEMENTS WITH TWO ADDITIONAL HOSPITALS AND ONE NURSING HOME. SINCE ITS INCEPTION IN 1992, MAYO CLINIC HEALTH SYSTEM HAS GROWN INTO ONE OF THE MOST SUCCESSFUL REGIONAL HEALTH CARE SYSTEMS IN THE UNITED STATES. MORE THAN 600,000 UNIQUE PATIENTS ACCOUNT FOR MORE THAN 2.6 MILLION VISITS ANNUALLY IN MAYO CLINIC HEALTH SYSTEM. IT IS ALSO A NATIONAL LEADER IN QUALITY AND SAFETY EFFORTS.MCHS-LAKE CITY OWNS AND OPERATES AN 18 BED CRITICAL ACCESS HOSPITAL SERVING LAKE CITY, MINNESOTA AND SURROUNDING COMMUNITIES. DURING THE YEAR ENDED DECEMBER 31, 2014, LAKE CITY HAD 213 MEDICAL/SURGICAL ADMISSIONS, 58 OBSTETRIC ADMISSIONS, 58 DELIVERIES AND 153 SWING BED ADMISSIONS WITH AN AVERAGE DAILY CENSUS OF 8.67. IN ADDITION, THERE WERE 2,728 EMERGENCY ROOM VISITS, 349 SAME DAY SURGERIES AND ANCILLARY SERVICES INCLUDING LABORATORY, CARDIAC REHABILITATION, PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY, AND RADIOLOGY SERVICES. RADIOLOGY SERVICES INCLUDED MAMMOGRAPHY, CT, MRI AND ULTRASOUND.MCHS-LAKE CITY ALSO OWNS AND OPERATES FOUR CLINICS LOCATED IN ALMA, WISCONSIN AND IN LAKE CITY, PLAINVIEW AND WABASHA, MINNESOTA. THESE CLINICS ARE STAFFED BY ELEVEN FAMILY MEDICINE PHYSICIANS, A GENERAL SURGEON, TWO PHYSICIAN ASSISTANTS, AND FIVE NURSE PRACTITIONERS, INCLUDING A CERTIFIED NURSE-MIDWIFE. ON AN ANNUAL BASIS, THERE ARE APPROXIMATELY 57,260 PATIENT VISITS AMONG THE FOUR CLINIC LOCATIONS.MCHS-LAKE CITY CONTINUES TO PROVIDE A VENTILATOR PROGRAM TO ENSURE CONTINUUM OF CARE AND THE MOST APPROPRIATE PLACEMENT AND LEVEL OF CARE FOR VENTILATED AND OTHER PATIENTS REQUIRING A HIGH LEVEL OF RESPIRATORY CARE. THE ULTIMATE GOAL IS TO WEAN THE PATIENTS FROM THE VENTILATOR. MCHS-LAKE CITY HAS COMMITTED ELEVEN BEDS IN THE FACILITY FOR CARING FOR THIS KIND OF PATIENT POPULATION, ALONG WITH PROVIDING CLASSROOM AND SKILLS TRAINING FOR NURSING STAFF AND PROVIDERS.MCHS-LAKE CITY ALSO OPERATES LIFELINE (AN EASY-TO-USE PERSONAL RESPONSE SERVICE) TO ENSURE THAT OLDER ADULTS LIVING AT HOME CAN GET QUICK ASSISTANCE WHENEVER IT MAY BE NEEDED - 24 HOURS A DAY, 365 DAYS A YEAR. WHEN THE PERSONAL HELP BUTTON IS PRESSED, A MCHS-LAKE CITY MONITOR RESPONDS, ASSESSES THE SITUATION AND SUMMONS APPROPRIATE HELP. THERE WERE APPROXIMATELY 90 SUBSCRIBERS TO THE PROGRAM DURING 2014.MCHS-LAKE CITY PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS FINANCIAL ASSISTANCE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. SERVICES ARE ALSO PROVIDED TO BOTH MEDICAID AND MEDICARE PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. IN ADDITION, SERVICES ARE PROVIDED TO PATIENTS UNDER OTHER MEANS TESTED GOVERNMENT PROGRAMS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. IN 2014, MCHS-LAKE CITY PROVIDED APPROXIMATELY $839,000 IN FINANCIAL ASSISTANCE (AT COST) TO PATIENTS. THE UNREIMBURSED COST OF SERVICES TO PATIENTS UNDER OTHER MEANS TESTED GOVERNMENT PROGRAMS WAS APPROXIMATELY $531,000 WHICH INCLUDES MNCARE TAX OF $408,748.LAKE CITY HAS APPROXIMATELY 149 VOLUNTEERS INCLUDING INDIVIDUALS AND SERVICE GROUPS WHO PROVIDED APPROXIMATELY 5,338 HOURS OF VOLUNTEER SERVICES DURING 2014. THEY STAFF THE INFORMATION DESK DIRECTING PATIENTS AND VISITORS TO THEIR DESTINATION AND PERFORM CLERICAL DUTIES FOR VARIOUS DEPARTMENTS IN THE MEDICAL CENTER. BASED ON THE 2014 INDEPENDENT SECTOR STATISTICS, THE APPROXIMATE VALUE OF THESE SERVICES IS $123,148.MAYO CLINIC HEALTH SYSTEM-LAKE CITY PROVIDES SUPPORT SERVICES TO AFFILIATED ORGANIZATIONS TO HELP FURTHER THEIR EXEMPT PURPOSE OF PROVIDING PATIENT CARE. 7707679 7337771 RESIDENT SERVICES (NURSING HOME) - SEE SCHEDULE OMAYO CLINIC HEALTH SYSTEM - LAKE CITY (MCHS-LAKE CITY) ALSO OWNS AND OPERATES A 90-BED NURSING HOME THAT SEEKS TO ENHANCE RESIDENT'S QUALITY OF LIFE BY HELPING INDIVIDUALS MAINTAIN THEIR HEALTH AND SELF-RELIANCE. RESIDENTS ARE PROVIDED WITH 24-HOUR NURSING CARE, A ROOM, NUTRITIONALLY WELL-BALANCED MEALS, SNACKS, HOUSEKEEPING AND LAUNDRY SERVICES, ACTIVITY PROGRAMS, AND SOCIAL SERVICES ASSISTANCE AS NEEDED OR REQUESTED. RESIDENTS ALSO HAVE ACCESS TO SPECIALIZED SERVICES SUCH AS REHABILITATION SERVICES, REGISTERED DIETICIAN SERVICES, BEAUTY AND BARBER SERVICES, TELEPHONE SERVICES AND TELEVISION/CABLE SERVICES FOR AN ADDITIONAL FEE. THE AVERAGE DAILY CENSUS FOR THE NURSING HOME IN 2014 WAS 85.52.THE NURSING HOME'S DIETARY DEPARTMENT PROVIDES MEALS ON A DAILY BASIS FOR THE LAKE CITY HOME DELIVERED MEALS PROGRAM. MEALS ARE DELIVERED BY LIONS CLUB VOLUNTEERS TO LAKE CITY RESIDENTS WHO HAVE BEEN REFERRED TO THE PROGRAM BY HEALTHCARE PROVIDERS. MCHS-LAKE CITY PROVIDES THE ADMINISTRATION FOR THE PROGRAM INCLUDING REGISTRATION, NUTRITION PLANNING, MEAL PREPARATION, AND BILLING. THIS SERVICE ALLOWS SENIOR CITIZENS AND OTHERS WITH MEDICAL NEEDS TO LIVE INDEPENDENTLY FOR LONGER THAN WOULD OTHERWISE BE POSSIBLE. 24416 9718 650 COMMUNITY BENEFIT - SEE SCHEDULE O:AS PART OF ITS ACTIVITIES, MAYO CLINIC HEALTH SYSTEM - LAKE CITY (MCHS-LAKE CITY) PROVIDES VARIOUS SUPPORT GROUPS AND PROGRAMS TO THE COMMUNITY AT NO CHARGE. THESE GROUPS AND CLASSES INCLUDE CARDIAC SUPPORT GROUPS INCLUDING 73 PARTICIPANTS IN CARDIAC REHAB PHASE 3 AND 125 PARTICIPANTS IN CARDIAC SUPPORT GROUP, DIABETIC EDUCATIONAL PROGRAMS, A BREAST CANCER SUPPORT GROUP, AND OUTREACH FOR CITIZENS WHERE OUTREACH NURSES CONDUCTED BLOOD PRESSURE AND BLOOD SUGAR SCREENING FOR 1,822 PERSONS, MENTORING PROGRAMS AND PRENATAL CLASSES FOR EXPECTANT PARENTS.MCHS-LAKE CITY OFFERED SPORTS PHYSICALS AT A REDUCED RATE FOR STUDENTS WHO ARE PARTICIPATING IN SPORTS THROUGH THE LOCAL SCHOOLS, A PREVENTATIVE INJURY TRAINING PROGRAM, CONCUSSION SCREENING FOR 25 STUDENTS, FREE SKIN SCREENINGS AT LOCAL WRESTLING MEETS, AND STAFF ATTENDANCE AT HOME HIGH SCHOOL FOOTBALL GAMES TO RESPOND TO EMERGENCIES. MCHS-LAKE CITY ALSO HAS A PROGRAM THAT ALLOWS LOCAL HIGH SCHOOL STUDENTS TO COME ON-SITE AND LEARN ABOUT HEALTHCARE-RELATED CAREERS AND PARTICIPATE IN JOB SHADOWING EXPERIENCES. 42 STUDENTS PARTICIPATED IN HEALTH CAREER CLASS PRESENTATIONS. ALSO DURING 2014, MCHS-LAKE CITY PROVIDED $1,000 FOR SCHOLARSHIPS TO STUDENTS PURSUING A FIELD IN HEALTH CARE AND $8,718 IN DONATIONS TO LOCAL CHARITIES OR COMMUNITY ORGANIZATIONS. 33832156 1 1 0 1 0 0 0 0 1 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 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 11 0 1 335 1 0 0 0 0 0 0 0 0 0 0 X 8 4 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 0 0 MN WI X CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 GARTNER PHILLIP A DIRECTOR 1.00 0.00 X 0 0 0 GRUBER JOHN DIRECTOR 1.00 0.00 X 0 0 0 KEENAN AARON DIRECTOR (1/1-9/16) 1.00 40.00 X 0 143429 36836 MAHN DAVID DIRECTOR 1.00 0.00 X 0 0 0 SCHAAL MELISSA DIRECTOR 1.00 0.00 X 0 0 0 SOLBERG MD JEREMY J DIRECTOR 40.00 0.00 X 253199 0 47833 SPANO MD DENNIS C VICE-CHAIR / DIRECTOR 40.00 0.00 X X 515463 0 57273 WILKINSON MD JOHN M DIRECTOR 1.00 40.00 X 0 244088 18065 WITT MD THOMAS J CHAIR / CEO / DIRECTOR 40.00 0.00 X X 456792 0 66580 AGERTER MD DAVID C REGION CEO 1.00 40.00 X 0 555112 18208 GUDGELL STEPHEN F RIVER CORRIDOR CAO/TREAS(3/27-12/31) 1.00 40.00 X 0 196790 19698 KOCH MARK B ASSISTANT SECRETARY 1.00 40.00 X 0 395727 18025 PARKS DOUGLAS A REGION CAO 1.00 40.00 X 0 232013 50759 STIENE SUSAN M SECRETARY 40.00 0.00 X 160222 0 46392 TARASOVITCH JAMES J REGION CFO 1.00 40.00 X 0 354461 28513 ADAMSON MD STEVEN C PHYSICIAN 40.00 0.00 X 334708 0 54094 ANDERSON DO TRENT D PHYSICIAN 40.00 0.00 X 271211 0 31710 JESKE MD ROBERT D PHYSICIAN 1.00 40.00 X 103017 163175 41502 RENELT MD JOHN A PHYSICIAN 40.00 0.00 X 393907 0 60466 SCHWEND DO PHILLIP P PHYSICIAN 40.00 0.00 X 263007 0 65913 BROWN MARK C FMR COO 0.00 40.00 X 0 150748 33847 2751526 2435543 695714 28 1 1 0 MAYO CLINIC 200 1ST STREET SW ROCHESTER MN 55905 MEDICAL & SUPPORT SERVICES 741408 CENTREX REHAB 1007 E 14TH ST MINNEAPOLIS MN 55404 PURCHASE SERVICES 507294 SAINT ELIZABETH MEDICAL CENTER 1200 GRAND BLVD W WABASHA MN 55981 MEDICAL SERVICES 301608 AMN HEALTHCARE INC FILE 56157 LOS ANGELES CA 90074 PURCHASE SERVICES 179340 SODEXO OPERATIONS LLC 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 MANAGEMENT FEES 177794 7 1140 107871 344397 453408 NET PATIENT REVENUE 620000 38459753 38459753 NURSING HOME REVENUE 623110 7337771 7337771 SHARED SERVICES REVENU 561000 63466 63466 LIFELINE 621990 30980 30980 45891970 1143 1143 40304 38713 1591 1591 1591 742683 653103 89580 89580 89580 19291 5955 13336 13336 CAFETERIA/VENDING REVE 722210 115099 100284 14815 MISC. REVENUE 900099 9815 9815 MEDICAL RECORD/TRANSCR 541900 1325 1325 126239 46577267 46003394 0 120465 X 8718 8718 1000 1000 1603755 1603755 114957 114957 12282673 10959099 1292839 30735 311784 269788 41021 975 2245476 2014762 225357 5357 865999 782514 81546 1939 6094027 5595161 498866 1401 1401 203 203 10370280 5087641 5282639 7240 7240 1899697 1732539 167025 133 110168 110168 906143 586295 319848 183381 121115 62266 31857 31857 806528 791557 14971 191489 191489 MEDICAL SUPPLIES 2511006 2511006 BAD DEBT EXPENSE 549286 549286 MEDICAID SURCHARGE 540621 540621 MN CARE TAX 408748 408748 161264 11366 149898 42207701 33832156 8336406 39139 106645 99343 24435 20341 3872 0 6598418 7074944 19167 5000 507270 543455 387178 246314 24211802 12945208 12038285 11266594 9974879 15499502 311820 0 29971969 34755493 2928295 3124630 24435 20338 731206 955926 3683936 4100894 X 26288033 30654599 26288033 30654599 29971969 34755493 X 4369566 -3000 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 203 203 0 PART II-B, LINE 1: THE AMOUNT IN "OTHER ACTIVITIES" REPRESENTS A PORTION OF PROFESSIONAL DUES ATTRIBUTABLE TO LOBBYING. MAYO CLINIC HEALTH SYSTEM-LAKE CITY PROVIDES INFORMATION OR EXPRESSES ITS CONCERNS TO LEGISLATIVE BODIES AND GOVERNMENT OFFICIALS ON MATTERS DIRECTLY RELATED TO HEALTH, THE DELIVERY OF HEALTH CARE AND MEDICAL EDUCATION AND/OR RESEARCH. IN 2014, MCHS-LAKE CITY REPRESENTATIVES HAD A MEETING WITH MEMBERS OF THE LEGISLATIVE AND EXECUTIVE BRANCHES OF GOVERNMENT TO DISCUSS ISSUES RELATING TO HEALTH CARE AND HEALTH CARE REFORM. 0 1 X 101866 101866 17192 17143106 7483393 9676905 6807064 5461815 1345249 142574 142574 11266594 MAYO POOLED INVESTMENTS 15499502 F 15499502 DUE TO AFFILIATES 955926 955926 X PART IV, LINE 2B: NURSING HOME RESIDENT TRUST ACCOUNT - RESIDENTS' FUNDS. PART X, LINE 2: AT DECEMBER 31, 2014 AND 2013, THE RESERVE FOR UNRECOGNIZED TAX BENEFITS WAS NOT SIGNIFICANT, AND AS A RESULT, THERE IS NO LONGER A RESERVE FOR UNRECOGNIZED TAX BENEFITS RECORDED FOR THE FILING ORGANIZATION. SILENT AUCTION 6400 6400 6400 6400 6400 1 1 X 1 X 1 X 1 1 0 1 1 839246 839246 0.02010 4603157 4399323 203834 0.00490 1117318 586095 531223 0.01280 6559721 4985418 1574303 0.03780 23416 650 22766 0.00050 1000 1000 0.00000 14944814 9080464 5864350 0.14080 3288 3288 0.00010 14972518 9081114 5891404 0.14140 21532239 14066532 7465707 0.17920 5220 5220 0.00010 11430 11430 0.00030 8718 8718 0.00020 25368 25368 0.00060 0 549286 10429728 10416940 12788 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM - LAKE CITY 500 WEST GRANT STREET LAKE CITY MN 55041 WWW.MAYOCLINICHEALTHSYSTEM.ORG 20693 X X X X MAYO CLINIC HEALTH SYSTEM - LAKE CITY 1 0 0 1 X X X X X X X 13 1 1 0 1 X HTTP://MAYOCLINICHEALTHSYSTEM.ORG/ABOUT-US/ X 1 13 0 1 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X X X X X X X X X 1 X 0 X X X X X 1 X 0 0 MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 5: INPUT WAS PROVIDED BY THE HEALTHY COMMUNITIES SUPERVISOR AND COMMUNITY HEALTH SPECIALIST OF THE PUBLIC HEALTH DIVISION OF GOODHUE COUNTY HEALTH AND HUMAN SERVICES AND THE DIRECTOR OF WABASHA COUNTY PUBLIC HEALTH. IN ADDITION, INPUT WAS RECEIVED FROM KEY INFORMANT INTERVIEWS, COUNTY-WIDE MAIL SURVEYS, LOCAL FOCUS GROUPS, AND SURVEYS COMPLETED BY THE SCHOOL DISTRICTS, AND THE CHEMICAL HEALTH INITIATIVE. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 6A: MAYO CLINIC HEALTH SYSTEM-CANNON FALLS, MAYO CLINIC HEALTH SYSTEM-LAKE CITY AND MAYO CLINIC HEALTH SYSTEM-RED WING COLLABORATED ON THE CHNA WHICH ENCOMPASSES THE COUNTIES THAT THE THREE HOSPITALS SERVE. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 11: MAYO CLINIC IS A NOT-FOR-PROFIT ORGANIZATION WITH THE MISSION TO INSPIRE HOPE AND CONTRIBUTE TO HEALTH AND WELL-BEING BY PROVIDING THE BEST CARE TO EVERY PATIENT THROUGH INTEGRATED CLINICAL PRACTICE, EDUCATION, AND RESEARCH. AS PART OF MAYO CLINIC, MAYO CLINIC HEALTH SYSTEM OFFERS A VARIETY OF HEALTH CARE OPTIONS TO THE COMMUNITIES IT SERVES, RANGING FROM PRIMARY AND SPECIALTY CARE TO MORE COMPLEX CARE AT MAYO CLINIC. THE RESIDENTS OF CANNON FALLS, LAKE CITY AND RED WING ALSO BENEFIT FROM MAYO CLINIC EDUCATION AND RESEARCH EFFORTS SO BEST PRACTICES IDENTIFIED ARE IMPLEMENTED LOCALLY TO ASSURE THE HIGHEST STANDARDS OF CARE, QUALITY AND SAFETY. ONGOING PARTNERSHIPS WITH LOCAL PUBLIC HEALTH, SENIOR SERVICE PROGRAMS, NON PROFITS AND OTHER COMMUNITY ORGANIZATIONS ARE INTEGRAL TO IMPROVING THE HEALTH AND QUALITY OF LIFE FOR AREA RESIDENTS. WITH THE COMMUNITY HEALTH NEEDS ASSESSMENTS AND SUBSEQUENT SURVEYS, COMMUNITY MEETINGS AND INTERVIEWS, OUR CONTINUING WORK WITH OUR COMMUNITY PARTNERS HAVE NEVER BEEN MORE IMPORTANT. WE APPRECIATE THE UNIQUE PERSPECTIVES AND INSIGHTS THAT ALL COMMUNITY GROUPS CONTRIBUTE AS WE COLLECTIVELY IDENTIFY HEALTH AND SOCIAL ISSUES AND WORK TOWARD IMPROVING THE HEALTH STATUS OF OUR COMMUNITY. MAYO CLINIC HEALTH SYSTEM IN CANNON FALLS, LAKE CITY, AND RED WING (MCHS-CANNON FALLS/LAKE CITY/RED WING) COLLABORATED ON A JOINT COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS, IDENTIFIED COMMON NEEDS, AND DEVELOPED THE FOLLOWING JOINT IMPLEMENTATION PLANS TO ADDRESS THE NEEDS IDENTIFIED IN THE ASSESSMENT.IDENTIFIED NEED: OBESITYGOAL: INCREASE AWARENESS OF INDIVIDUAL HEALTH AND OBESITY MANAGEMENT OPTIONS FOR YOUTH AND FAMILIES.IMPLEMENTATION PLAN UPDATE:SOCIAL MEDIA STRATEGY - MCHS- CANNON FALLS/LAKE CITY/RED WING UTILIZED SOCIAL MEDIA TO PROMOTE THE MAYO MESSAGES FOR HEALTHY ACTIVITY AND NUTRITION. PINS AND POSTS THAT FOLLOW TRENDS AND HEALTH EVENTS ARE UPDATED DAILY. THE TEAM CONTINUES TO WORK ON HOW TO QUANTIFY THE EFFECT THESE HEALTHY AND POSITIVE MESSAGES HAVE ON THE REGION. SOCIAL MEDIA ALLOWS VARIOUS DEMOGRAPHIC AUDIENCES THAT INCLUDE MALES AND FEMALES AGES 18-64 TO RECEIVE EDUCATION AND ENGAGE ONLINE WITH MAYO CLINIC HEALTH SYSTEM. MCHS SOCIAL MEDIA CHANNELS INCLUDE: FACEBOOK, TWITTER, YOUTUBE, PINTEREST AND GOOGLE PLUS. EXAMPLES OF STRATEGIC SOCIAL MEDIA CAMPAIGNS INCLUDE RUNNING TIPS, HEALTHY RECIPES, HEART HEALTH TIPS, EXERCISE, AND WELLNESS INFORMATION. WRITTEN CONTENT, PHOTOS AND VIDEOS ARE INCORPORATED AS APPLICABLE IN EACH SOCIAL MEDIA CHANNEL. 5210 STRATEGY - THE 5210 PROGRAM HAS BEEN PROMOTED IN PEDIATRICS AND FAMILY PRACTICE THROUGHOUT WABASHA COUNTY BY WORKING WITH THE HEALTH DEPARTMENT'S STATE HEALTH IMPROVEMENT PROGRAM. THE 5210 PROGRAM IS A SPECIFIC PROGRAM TO REDUCE SCREEN TIME (TV, COMPUTER, IPAD AND GAMES) AND INCREASE EXERCISE AND ACTIVITY OF ELEMENTARY STUDENTS FOR ONE MONTH. BIKES WERE GIVEN AS REWARDS FOR THOSE WHO SUCCESSFULLY ELIMINATED EXCESS SCREEN TIME FROM THEIR DAY. COMMUNITY EVENT SPONSORSHIP - MCHS CANNON FALLS/LAKE CITY/RED WING PARTNERED WITH LOCAL NONPROFITS TO ENCOURAGE YOUTH ACTIVITY SUCH AS THE LAKE CITY SCHOOLS BIKE PROGRAM, CANNON FALLS BIKE EVENT, "GET READY TO RAMBLE", THE CANNON VALLEY TRAIL, AND RED WING'S "OPEN YOUR DOOR" CAMPAIGN FOR MAPS AND TRAILS. NUTRITION AND COOKING EVENTS WERE HELD AT THE FARMERS MARKET WITH THE SUSTAINABILITY COMMISSION. FREE EDUCATION AND SCREENINGS WERE GIVEN BY THE OUTREACH NURSES WHO HAD INDIVIDUAL CONTACT WITH 1,822 PERSONS. IN ORDER TO ROLE MODEL ACTIVITY, MINI FRISBEES ARE DISTRIBUTED RATHER THAN TREATS AT YOUTH EVENTS, BIKE HELMETS ARE USED AS GIVE A WAYS, COOKBOOKS ARE DISTRIBUTED AND MCHS SPONSORS HEALTHY LIVING COMMUNITY EVENTS INCLUDING BIKE RALLYS AND RUN/WALKS.IMPROVE EMPLOYEE HEALTH STRATEGY - MCHS CANNON FALLS/LAKE CITY/RED WING EMPLOYEES MODEL HEALTH STRATEGIES AND ARE INFLUENCERS IN ALL THE COMMUNITIES MCHS SERVES. EMPLOYEE HEALTH AND WELLNESS CONDUCTED A "TAKE YOUR BREAK" EXERCISE PROGRAM WITH 60 EMPLOYEES ATTENDING AND CHANGING DAILY OFFICE HABITS. WALKING MEETING TRAINING WAS HELD AT A LEADERSHIP DEVELOPMENT INSTITUTE AND EMPLOYEES ARE ENCOURAGED TO CONDUCT WALKING MEETINGS. MCHS CANNON FALLS AND LAKE CITY HAVE PATHS MAPPED IN AND AROUND THEIR FACILITIES TO ENCOURAGE WALKING BREAKS FOR ALL STAFF. IDENTIFIED NEED: ACCESSGOAL: TO SUPPORT AND PROMOTE COMMUNITY HEALTH CARE ACCESS.IMPLEMENTATION PLAN UPDATE: MCHS CANNON FALLS/LAKE CITY/RED WING PARTNERS WITH LOCAL VOLUNTEERS, COUNTY SERVICES, THE CARE FREE CLINIC BOARD OF DIRECTORS AND CARE CLINIC STAFF TO MAINTAIN THE FREE CLINIC FOR OUR SERVICE AREA. MALPRACTICE INSURANCE IS PROVIDED FOR ALL MCHS EMPLOYEES WHO VOLUNTEER AT THE CLINIC. MCHS PROVIDES $15,000 IN LAB AND RADIOLOGY SERVICES BILLED AT A MEDICARE LEVEL FOR CARE PATIENTS SO THE CARE CLINIC CAN INCREASE THE SCOPE OF SERVICES THEY PROVIDE WITHOUT ADDITIONAL FEES TO THE PATIENTS. THE CARE CLINIC IS LOCATED IN THE MCHS BUILDING THAT WAS PREVIOUSLY THE RED WING HOSPITAL EMERGENCY ROOM. THE SPACE IS PROVIDED FREE OF CHARGE. TECHNOLOGY IS PROVIDED TO CONNECT THE VOLUNTEER PROVIDERS WITH THE PATIENT RECORDS AND TEST RESULTS WHILE MAINTAINING THE HIGHEST LEVEL OF PATIENT CONFIDENTIALITY. SPECIALTY SERVICES (DIABETES, OPHTHALMOLOGY) CLINICS ARE SUPPORTED WITH TIME AND EQUIPMENT. MCHS-CANNON FALLS INVITED NONPROFIT ORGANIZATIONS TO CHOOSE ITEMS THEY NEEDED FROM THE EQUIPMENT THAT WAS NOT MOVED TO THE NEW FACILITY. THE NURSE TRIAGE LINE PROMOTES ACCESS TO SERVICES FOR COMMUNITY MEMBERS WHETHER THEY ARE CURRENT OR NON-CURRENT PATIENTS. THE TRIAGE STAFF ARE ABLE TO DIRECT INDIVIDUALS WHO CALL ASKING FOR ADVICE TO APPROPRIATE LEVELS OF SERVICE AND MANY TIMES ARE ABLE TO SAVE THEM FROM AN APPOINTMENT BY PROVIDING OVER THE COUNTER OPTIONS. LIMITED PROTOCOLS CAN BE SHARED WITH NON PATIENTS INCREASING THEIR ACCESS TO CARE. THIS SERVICE IS STILL BEING ASSESSED AND WILL BE EVALUATED IN THE 2015 CHNA IMPLEMENTATION REVIEW.IDENTIFIED NEED: MENTAL HEALTHGOAL: EDUCATE AND PROVIDE RESOURCES FOR THE COMMUNITY BY UTILIZING SOCIAL MEDIA TO EDUCATE THE COMMUNITY.IMPLEMENTATION PLAN UPDATE: DR. SOOD'S "GUIDE TO STRESS FREE LIVING" BOOK HAS HAD MULTIPLE FACEBOOK POSTS TO PROMOTE MENTAL HEALTH AND PERSONAL STRESS MANAGEMENT. A COMMUNITY COLLABORATION LED BY MCHS CANNON FALLS/LAKE CITY/RED WING AND THE RED WING SHOE FOUNDATION SUCCEEDED IN MEETING THEIR THREE ESTABLISHED GOALS - 1) COUNTY WIDE RESOURCE LISTS WERE DEVELOPED AND SHARED, 2) NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI) CHAPTER WAS REINSTATED IN GOODHUE COUNTY, AND 3) THE "MAKE IT OK" ANTI STIGMA PROGRAM WAS PROMOTED TO 1,263 PERSONS THROUGH EMPLOYERS AND IN TWELVE COMMUNITY SESSIONS. MENTAL HEALTH FIRST AID TRAINING WAS HELD IN TWO LOCATIONS IN GOODHUE COUNTY AND ADDITIONAL PARTICIPANTS ATTENDED TRAINING IN A NEIGHBORING COUNTY. IN TOTAL 42 COMMUNITY MEMBERS COMPLETED THE 8 HOUR TRAINING. THE GOAL OF "EVERY HAND JOINED" IS TO HELP YOUNG PEOPLE REACH THEIR FULL POTENTIAL FROM CRADLE TO CAREER. THE PROGRAM GIVES THEM THE KNOWLEDGE AND STRENGTHS NEEDED TO SUCCEED IN THE 21ST CENTURY. "EVERY HAND JOINED" FOCUSES ON THREE AREAS WHERE EXTRA SUPPORT WILL MAKE A LONG-TERM IMPACT ON SUCCESS. IT CURRENTLY INCLUDES: KINDERGARTEN READINESS, 3RD GRADE READING SKILLS, AND MATH SCORES. IMPROVE EMPLOYEE MENTAL HEALTH: UNDER THE EMPLOYEE ASSISTANCE (EAP) PROGRAM, NEWSLETTERS AND EDUCATIONAL FLYERS ARE DISTRIBUTED TO EMPLOYEES. THE EAP STAFF ATTEND AN ANNUAL EMPLOYEE HEALTH FAIR, IN ADDITION TO, ANTI STIGMA TRAINING AND BEHAVIORAL HEALTH PROMOTIONS INCLUDING CHAIR MASSAGES AND YOGA PROGRAMS.IDENTIFIED NEED: HIGHWAY SAFETYIMPLEMENTATION PLAN UPDATE: THE CITY OF CANNON FALLS SPECIFICALLY ASSESSED THE NEED TO INCREASE SAFETY ON HIGHWAY 52. AFTER THE ASSESSMENT WAS COMPLETE, THE STATE REVEALED PLANS TO ELIMINATE ALL CROSSOVER TRAFFIC IN CANNON FALLS. THESE CHANGES WERE IMPLEMENTED AS PART OF THE HIGHWAY 52 RECONSTRUCTION DURING 2014. A COMMUNITY GROUP HAS BEEN FORMED TO LEAD DISCUSSIONS ON REOPENING ONE OF THE HIGHWAY 52 CROSSINGS. IF THIS HAPPENS, THIS SAFETY NEED WILL NEED TO BE ADDRESSED AT THAT TIME. NEEDS NOT BEING ADDRESSED WITH ADDITIONAL RESOURCES: CHEMICAL HEALTH: THIS NEED IS BEING ADDRESSED IN THE COUNTY. MCHS-CANNON FALLS AND MCHS-RED WING ARE PARTNERS WITH THE GOODHUE COUNTY CHEMICAL HEALTH INITIATIVE AND THEY ARE IN THE FINAL YEAR OF A TEN YEAR GRANT PROCESS. THIS NEED MAY RESURFACE IN THE NEXT ASSESSMENT AND WILL BE EVALUATED AT THAT TIME.TOBACCO: PROGRAMS ARE SUPPORTED IN THE COUNTY THROUGH HEALTH AND HUMAN SERVICES. MCHS-RED WING DOES HAVE A CESSATION PROGRAM AND WORKS WITH OTHER STATE AND LOCAL REDUCTION EDUCATION PROGRAMS. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 13H: THE REGIONAL PROXIMITY OF A PATIENT'S RESIDENCY IS A FACTOR FOR PRESCHEDULED SERVICES ONLY AND SECONDARY TO MEDICAL NEED. REGIONAL PROXIMITY IS NOT A FACTOR FOR EMERGENCY CARE PROVIDED. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 16I: WITH REGARD TO THE POSTINGS WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE ARE DISCUSSED WITH THE PATIENT. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 20E: FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE TO EVERY PATIENT VIA MAYO'S PUBLIC WEBSITE, FROM CUSTOMER SERVICE AND PATIENT ACCESS LOCATIONS, AND IS REFERENCED ON MAYO'S AUTHORIZATION FORMS AND STATEMENTS. IN ADDITION, BROCHURES ARE AVAILABLE IN THE ADMISSIONS AREA AND THE PROCESS OF HOW TO APPLY IS AVAILABLE ON THE MAYO CLINIC WEBSITE.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, MAYO DISCUSSES ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE.MONTHLY STATEMENTS ARE SENT TO PATIENTS THAT OUTLINE CURRENT CHARGES AND ACTIONS WITH INSURANCE AND INCLUDES INFORMATION ABOUT MAYO'S CHARITY CARE POLICY. SOME MAYO SITES UTILIZE ADVOCATES TO CONTACT THE PATIENT UPON DISCHARGE TO HELP THEM SECURE GOVERNMENTAL ASSISTANCE OR FINANCIAL ASSISTANCE.EACH CHARITY CARE REVIEW IS DOCUMENTED IN MAYO'S BILLING SYSTEM AND COMMUNICATED TO THE PATIENT. COMPLETED CHARITY CARE FORMS ARE MAINTAINED EITHER IN PAPER OR ELECTRONIC FORMAT. THE PATIENT IS INFORMED REGARDING THE OUTCOME OF THE REVIEW.MAYO OFTEN IDENTIFIES CHARITY CARE OPPORTUNITIES AFTER THE PATIENT HAS BEEN DISMISSED. IN MANY CASES, THIS IS DUE TO LIMITED INSURANCE COVERAGE OR INSURANCE DENIALS AFTER THE SERVICE WAS PERFORMED. IN THESE CASES, WHEN A PATIENT EXPRESSES AN INABILITY TO PAY FOR THEIR SERVICES, STAFF WILL INITIATE A CHARITY REVIEW AS INDICATED BY THE FINANCIAL ASSISTANCE POLICY, WHICH IS AVAILABLE FOR EVERY PATIENT AT MAYOCLINIC.ORG. MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 22D: OUR POLICY ALLOWS FOR A MINIMUM DISCOUNT OF 10% TO ELIGIBLE INDIVIDUALS WHICH RESULTS IN AN AMOUNT LESS THAN THE AVERAGE OF THE THREE BEST NEGOTIATED COMMERCIAL RATES OR THE BEST NEGOTIATED COMMERCIAL RATE. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 16A WEBSITE: SEE PART VI MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 16B WEBSITE: SEE PART VI MAYO CLINIC HEALTH SYSTEM - LAKE CITY PART V, SECTION B, LINE 16C WEBSITE: SEE PART VI 5 MCHS - LAKE CITY (CARE CENTER) 500 WEST GRANT STREET LAKE CITY MN 55041 NURSING HOME MCHS - LAKE CITY (LAKE CITY CLINIC) 500 WEST GRANT STREET LAKE CITY MN 55041 CLINIC MCHS - LAKE CITY (WABASHA CLINIC) 1202 5TH GRANT BLVD WEST WABASHA MN 55981 CLINIC MCHS - LAKE CITY (PLAINVIEW CLINIC) 275 1ST STREET SW PLAINVEIW MN 55964 CLINIC MCHS - LAKE CITY (ALMA CLINIC) 204 SOUTH MAIN STREET ALMA WI 54610 CLINIC PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A-7C (FINANCIAL ASSISTANCE, MEDICAID SHORTFALL, AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS).THE AMOUNTS FOR LINES 7E-7I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND WOULD NOT BE BASED ON A COST-TO-CHARGE RATIO. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 549,286. PART II, COMMUNITY BUILDING ACTIVITIES: THROUGH DONATIONS AND GRANTS TO PUBLIC, PRIVATE AND NONPROFIT ORGANIZATIONS, THE FILING ORGANIZATION ASSISTS WITH SUSTAINING AND ENHANCING THE COMMUNITIES IT SERVES. PART III, LINE 2: THE FILING ORGANIZATION REPORTS BAD DEBT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15 IS FOLLOWED TO THE EXTENT THAT IT ALIGNS WITH THE GUIDELINES SET FORTH BY GAAP.METHODOLOGY FOR SCHEDULE H, PART III, LINE 2:BAD DEBT EXPENSE IS DETERMINED BASED ON GAAP AND IS EXPLAINED IN THE ACCOUNTS RECEIVABLE FOOTNOTE OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART III, LINE 4: FOOTNOTES RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS CAN BE FOUND ON PAGES 5, 7, 8 AND 9 OF MAYO CLINIC'S 2014 CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE SURPLUS REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT (USING A MEDICARE COST REPORT STEP-DOWN METHODOLOGY).REASONS WHY MEDICARE SHORTFALL REPORTED ON LINE 7, IF ANY, SHOULD BE TREATED AS COMMUNITY BENEFIT ARE: (1) ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; (2) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; (3) THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS; AND (4) THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: MAYO CLINIC AND ITS AFFILIATES STRIVE TO ASSIST ALL PATIENTS IN MEETING THEIR FINANCIAL OBLIGATION PRIOR TO ENLISTING THE ASSISTANCE OF A COLLECTION AGENCY BY MAKING REASONABLE ATTEMPTS TO COLLECT FROM INSURANCE COMPANIES AND OTHER THIRD-PARTY PAYORS. IN ADDITION, MAYO CLINIC AND ITS AFFILIATES ACCEPT REASONABLE PAYMENT PLANS FROM PATIENTS WHEN AN ACCOUNT IS THE PATIENT'S RESPONSIBILITY AND TRY TO IDENTIFY THOSE PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. FINANCIAL ASSISTANCE IS OFFERED TO ANY PATIENT IF THE FACTS AND CIRCUMSTANCES SUGGEST THAT THE PATIENT DOES NOT HAVE THE ABILITY TO PAY THEIR BILL IN WHOLE OR IN PART. IN THE EVENT THAT AN ACCOUNT IS REFERRED TO A COLLECTION AGENCY, GUIDELINES ARE FOLLOWED; INCLUDING SUSPENDING ALL COLLECTION ACTIVITY IF A FINANCIAL ASSISTANCE APPLICATION HAS BEEN SUBMITTED AFTER THE ACCOUNT HAS BEEN REFERRED FOR COLLECTION. IF A COLLECTION AGENCY IDENTIFIES A PATIENT AS POTENTIALLY MEETING MAYO CLINIC'S FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA OR THE PATIENT ASKS TO APPLY FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY IS SUSPENDED UNTIL MAYO REVIEWS THE ACCOUNT FOR FINANCIAL ASSISTANCE ELIGIBILITY BASED ON SUBMISSION OF REQUESTED INFORMATION. COLLECTION ACTIVITY WOULD ONLY RESUME IF THE PATIENT IS DETERMINED TO BE INELIGIBLE FOR FINANCIAL ASSISTANCE OR IS ELIGIBLE FOR ONLY PARTIAL FINANCIAL ASSISTANCE AND DOES NOT AGREE TO PAY THE REMAINING BALANCE. PART VI, LINE 2: MAYO CLINIC HEALTH SYSTEM - LAKE CITY (MCHS-LAKE CITY) EMPLOYEES THROUGHOUT THE ORGANIZATION ASSESS THE NEEDS OF LAKE CITY AND THE SURROUNDING COMMUNITIES THROUGH PERSONAL INTERACTION AND INVOLVEMENT WITH LOCAL SCHOOLS, CIVIC GROUPS AND HEALTH DEPARTMENTS, AS WELL AS THROUGH THE COLLECTION AND ANALYSIS OF FEEDBACK FROM PATIENTS AND COMMUNITY MEMBERS.MCHS-LAKE CITY EMPLOYEES ARE ALSO STRONGLY CONNECTED WITH LOCAL CIVIC GROUPS. MANY EMPLOYEES ARE ACTIVE MEMBERS OF VARIOUS LAKE CITY ORGANIZATIONS, WHILE OTHERS GIVE HEALTHCARE PRESENTATIONS TO THESE GROUPS. THIS PARTICIPATION NOT ONLY PROMOTES INVOLVEMENT IN THE COMMUNITY, BUT ALSO GIVES COMMUNITY MEMBERS A CHANCE TO ASK QUESTIONS, SHARE COMMENTS, CONCERNS OR OTHER SUGGESTIONS THEY MAY HAVE REGARDING THE MEDICAL CENTER. MCHS-LAKE CITY PROVIDES PREVENTIVE HEALTH SCREENINGS THROUGHOUT THE COMMUNITY. MCHS-LAKE CITY ALSO WORKS WITH THE WABASHA PUBLIC HEALTH ORGANIZATION TO DEVELOP RELATIONSHIPS AMONG HEALTH CARE PROVIDERS AND COMMUNITY LEADERS. THIS PARTNERSHIP PROMOTES THE ACTIVE REFERRAL OF PATIENTS TO LOCAL RESOURCES SUCH AS ACCESS TO HIGH QUALITY NUTRITIOUS FOODS, PHYSICAL ACTIVITY AND TOBACCO USE CESSATION PROGRAMS. MCHS-LAKE CITY ACTIVELY SEEKS FEEDBACK FROM PATIENTS AND COMMUNITY MEMBERS THROUGH ITS PATIENT ADVISORY COUNCIL (PAC) AND PATIENT SATISFACTION SURVEYS. THE PAC IS A GROUP OF TEN COMMUNITY MEMBERS WHO SERVE AS A MCHS-CANNON FALLS/LAKE CITY /RED WING FOCUS GROUP TO PROVIDE FEEDBACK PRIOR TO THE IMPLEMENTATION OF NEW PROGRAMS AND SERVICES, ASSIST IN THE IDENTIFICATION OF OPPORTUNITIES THAT WILL IMPROVE PATIENT AND FAMILY SATISFACTION, PROVIDE TIMELY AND DIRECT INPUT INTO MCHS-LAKE CITY SYSTEM AND PROCESS CHANGES, OFFER INPUT TO LEADERSHIP IN THE PLANNING AND EVALUATION OF SERVICES, AND SERVE AS A VITAL LINK BETWEEN MCHS-LAKE CITY AND THE COMMUNITY.MCHS-LAKE CITY STAFF IS TRAINED TO IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE PROGRAMS. THE ORGANIZATION HAS PROGRAMS IN PLACE FOR FINANCIAL ASSISTANCE TO HELP THOSE WHO ARE IN NEED OF HEALTH CARE BUT HAVE NO INSURANCE OR ARE NOT ABLE TO RECEIVE OTHER FINANCIAL ASSISTANCE. AS THESE EXAMPLES OF INVOLVEMENT DEMONSTRATE, MCHS-LAKE CITY IS CLOSELY CONNECTED WITH THE COMMUNITY. IN ADDITION TO THIS, MCHS- LAKE CITY ACTIVELY SEEKS FEEDBACK FROM PATIENTS AND COMMUNITY MEMBERS THROUGH AVATAR SURVEYS. THE SURVEY IS SENT TO A CROSS SECTION OF PATIENTS TO COMPILE USEFUL FEEDBACK ON WAYS MCHS-LAKE CITY CAN IMPROVE CUSTOMER SERVICES AND DETERMINE WHETHER OR NOT THERE IS A NEED FOR NEW OR EXPANDED SERVICES. THE DATA FROM THE SURVEY IS REVIEWED AND ANALYZED BY MEMBERS OF QUALITY AND ADMINISTRATION DEPARTMENTS AS WELL AS MCHS-LAKE CITY EMERGENCY ROOM (ER)/INPATIENT SATISFACTION TEAM, A TEAM DEDICATED TO IMPROVING PATIENT SATISFACTION IN THE ER AND HOSPITAL.THROUGH THESE VARIOUS AVENUES, MCHS-LAKE CITY STAFF MEMBERS ACROSS MANY DEPARTMENTS STAY CONNECTED WITH THE COMMUNITY TO ASSESS THE HEALTHCARE NEEDS OF LAKE CITY AND SURROUNDING AREAS. PART VI, LINE 3: MEASURES TO PUBLICIZE FINANCIAL ASSISTANCE POLICY:MAYO CLINIC IS COMMITTED TO OFFERING FINANCIAL ASSISTANCE TO ELIGIBLE PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY FOR THEIR MEDICAL SERVICES IN WHOLE OR IN PART. IN ORDER TO ACCOMPLISH THIS CHARITABLE GOAL, MAYO CLINIC AND MAYO CLINIC HEALTH SYSTEM SITES WIDELY PUBLICIZE THIS POLICY IN THE COMMUNITIES THAT THE INDIVIDUAL MAYO CLINIC AFFILIATED SITES SERVE. MAYO CLINIC AFFILIATED SITES MAKE COPIES OF THIS POLICY AND APPLICATIONS AVAILABLE BY POSTING IT ON THEIR WEBPAGE INCLUDING THE ABILITY TO DOWNLOAD A COPY OF THE POLICY AND APPLICATION FREE OF CHARGE. INDIVIDUALS IN THE COMMUNITY SERVED WILL BE ABLE TO OBTAIN A COPY OF THE POLICY IN LOCATIONS THROUGHOUT EACH MAYO CLINIC AFFILIATED SITE OR UPON REQUEST. THE POLICY EXPLAINS THE FINANCIAL ASSISTANCE PROGRAM AND FACTORS AFFECTING ELIGIBILITY. WITHIN THE HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED. ADDITIONALLY, CHARITABLE CARE AND FINANCIAL ASSISTANCE IS REFERENCED ON PATIENT CORRESPONDENCE INCLUDING: THE MONTHLY STATEMENT OF ACCOUNT, ACCOUNT BALANCE LETTERS, AND LATE PAYMENT NOTIFICATIONS. ALL PATIENT CORRESPONDENCE REFERENCING CHARITABLE CARE AND FINANCIAL ASSISTANCE INCLUDE INTERNET, PHONE, AND MAILING ADDRESS CONTACT INFORMATION. PART VI, LINE 4: MCHS-LAKE CITY HAS LOCATIONS IN LAKE CITY, PLAINVIEW AND WABASHA, MINNESOTA, AS WELL AS IN ALMA, WISCONSIN. THE MAJORITY OF MCHS-LAKE CITY'S SERVICE AREAS INCLUDE GOODHUE AND WABASHA COUNTIES IN SOUTHEASTERN MINNESOTA AND BUFFALO COUNTY IN SOUTHWESTERN WISCONSIN. THE MAIN CAMPUS, LOCATED IN LAKE CITY, HOUSES AN 18-BED CRITICAL ACCESS HOSPITAL, A 90-BED NURSING HOME AND A HOSPITAL-BASED CLINIC WITH 37 PROVIDERS THAT SERVE LAKE CITY AND SURROUNDING COMMUNITIES. ACCORDING TO THE UNITED STATES CENSUS BUREAU, AND MINNESOTA COMPASS THE 2011 POPULATION FOR WABASHA COUNTY (WHICH COMPRISES MOST OF LAKE CITY'S SERVICE AREA) IS 21,443. A 2012 ESTIMATE REPORTS THAT THE POPULATION OF LAKE CITY IS 5,047, 20.7% OF THE POPULATION IS UNDER 18 YEARS OLD, AND 23.2% IS 65 YEARS OLD OR OLDER. THE MEDIAN HOUSEHOLD INCOME IS $47,145, AND AN ESTIMATED 5.6% OF INDIVIDUALS ARE LIVING BELOW POVERTY LEVEL. PART VI, LINE 5: THE FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES ARE LARGE, MULTI-FACETED, INTEGRATED, NOT-FOR-PROFIT GROUP PRACTICES AND HEALTH SYSTEMS. AT MAYO CLINIC, DOCTORS FROM EVERY MEDICAL SPECIALTY WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF "THE NEEDS OF THE PATIENT COME FIRST." THE ORGANIZATIONS (INCLUDING HOSPITAL AND NON-HOSPITAL ENTITIES) WORK TOGETHER TO SERVE THEIR COMMUNITIES AT THE LOCAL, REGIONAL, NATIONAL, AND GLOBAL LEVELS. THIS COMMUNITY BENEFIT HAPPENS THROUGH ITS FOCUS ON PATIENT CARE, EDUCATION, AND RESEARCH. SPECIFICALLY, THE TAX-EXEMPT PURPOSE OF MAYO CLINIC AND ITS AFFILIATES IS THREE-FOLD:PRACTICE - PRACTICE MEDICINE AS AN INTEGRATED TEAM OF COMPASSIONATE, MULTI-DISCIPLINARY PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS WHO ARE FOCUSED ON THE NEEDS OF PATIENTS FROM OUR COMMUNITIES, REGIONS, THE NATION AND THE WORLD.EDUCATION - EDUCATE PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS AND BE A DEPENDABLE SOURCE OF HEALTH INFORMATION FOR OUR PATIENTS AND THE PUBLIC.RESEARCH - CONDUCT BASIC AND CLINICAL RESEARCH PROGRAMS TO IMPROVE PATIENT CARE AND TO BENEFIT SOCIETY, INCLUDING PARTNERING WITH MAYO CLINIC HEALTH SYSTEM PRACTICES TO PERFORM PRACTICE-BASED RESEARCH DESIGNED TO IMPROVE PATIENT CARE.THROUGH ITS MISSION, MAYO CLINIC AND ITS AFFILIATES ENRICH THE COMMUNITIES IN WHICH THEY OPERATE AS WELL AS THE BROADER COMMUNITY - IMPROVING MEDICINE THROUGH RESEARCH, EDUCATING PHYSICIANS AND OTHER HEALTH CARE PROVIDERS, AND PROVIDING CARE AND SUPPORT TO PEOPLE IN NEED. PLEASE REFER TO THE PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, FOR FURTHER DESCRIPTION OF THE FILING ORGANIZATION'S ACTIVITIES.SURPLUS FUNDS:MAYO CLINIC AND ITS AFFILIATES REINVEST THEIR NET OPERATING INCOME TO ADVANCE MEDICAL RESEARCH AND TEACH THE NEXT GENERATION OF HEALTH CARE PROFESSIONALS, AS WELL AS TO ALLOW THE INDIVIDUAL ENTITY TO SUSTAIN ITS MISSION AND PREPARE FOR THE FUTURE. COMMUNITY REPRESENTATION ON GOVERNING BODY:THE BOARD OF TRUSTEES IS THE GOVERNING BODY OF MAYO CLINIC. A MAJORITY OF ITS MEMBERS ARE EXTERNAL, INDEPENDENT TRUSTEES. IT HAS OVERALL RESPONSIBILITY FOR THE CHARITABLE, CLINICAL PRACTICE, SCIENTIFIC AND EDUCATIONAL MISSION AND PURPOSES OF MAYO CLINIC AND ITS AFFILIATES AS SET FORTH IN ITS ARTICLES OF INCORPORATION AND BYLAWS. BECAUSE OF MAYO CLINIC'S NATIONAL PRESENCE, THESE TRUSTEES ARE SELECTED BASED ON THEIR AREAS OF EXPERTISE, WHETHER IN HEALTH CARE POLICY, BUSINESS, GOVERNMENT OR ANOTHER FIELD. IN ADDITION TO THIS COMMUNITY REPRESENTATION AT THE PARENT ENTITY, THE FILING ORGANIZATION ALSO INVOLVES LOCAL COMMUNITY MEMBERS ON ITS GOVERNING BODY. OPEN V. CLOSED STAFF MODEL:THE FILING ORGANIZATION'S STAFF PRIVILEGES ARE GENERALLY EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY.EMERGENCY ROOM:THE FILING ORGANIZATION MAINTAINS AN EMERGENCY ROOM 24 HOURS A DAY, 7 DAYS A WEEK, WHICH IS OPEN TO ALL WITHOUT REGARD TO THE ABILITY TO PAY. PART VI, LINE 6: THIS ORGANIZATION IS A PART OF MAYO CLINIC HEALTH SYSTEM (WHICH IS PART OF A LARGER GROUP OF ENTITIES AFFILIATED WITH MAYO CLINIC). THE MAYO CLINIC HEALTH SYSTEM IS DESCRIBED IN RESPONSE TO CORE FORM, PART III, STATEMENT OF PROGRAM ACCOMPLISHMENTS, LINE 4A (REPORTED IN SCHEDULE O). THAT STATEMENT ALSO DESCRIBES THE ROLES OF THE VARIOUS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED. PART VI, LINE 7 NEITHER THE FILING ORGANIZATION, NOR ANY RELATED ORGANIZATION, FILES A COMMUNITY BENEFIT REPORT WITH ANY STATE OTHER THAN THE EXTENT TO WHICH COMMUNITY BENEFIT INFORMATION IS INCLUDED IN OTHER REPORTING REQUIREMENTS SUCH AS INFORMATION PROVIDED TO A STATE HOSPITAL ASSOCIATION. PART V, SECTION B, LINES 16A, 16B, & 16C URL OF THE FAP, FAP APPLICATION, AND PLAIN LANGUAGE SUMMARY (BROCHURE):MAYOCLINICHEALTHSYSTEM.ORG/LOCATIONS/LAKE-CITY/BILLING X 1 1 0 1 1 0 0 0 0 0 0 KEENAN AARON DIRECTOR (1/1-9/16) 0 142929 0 0 0 500 0 15820 0 21016 0 180265 0 0 SOLBERG MD JEREMY J DIRECTOR 239301 0 0 0 13898 0 20482 0 27351 0 301032 0 0 0 SPANO MD DENNIS C VICE-CHAIR / DIRECTOR 311858 0 0 0 203605 0 27533 0 29740 0 572736 0 0 0 WILKINSON MD JOHN M DIRECTOR 0 229428 0 0 0 14660 0 223 0 17842 0 262153 0 0 WITT MD THOMAS J CHAIR / CEO / DIRECTOR 408368 0 0 0 48424 0 44943 0 21637 0 523372 0 0 0 AGERTER MD DAVID C REGION CEO 0 499015 0 0 0 56097 0 675 0 17533 0 573320 0 0 GUDGELL STEPHEN F RIVER CORRIDOR CAO/TREAS(3/27-12/31) 0 195549 0 0 0 1241 0 311 0 19387 0 216488 0 0 KOCH MARK B ASSISTANT SECRETARY 0 378314 0 0 0 17413 0 533 0 17492 0 413752 0 0 PARKS DOUGLAS A REGION CAO 0 230653 0 0 0 1360 0 24478 0 26281 0 282772 0 0 STIENE SUSAN M SECRETARY 156724 0 0 0 3498 0 27074 0 19318 0 206614 0 0 0 TARASOVITCH JAMES J REGION CFO 0 293754 0 0 0 60707 0 10400 0 18113 0 382974 0 0 ADAMSON MD STEVEN C PHYSICIAN 268298 0 0 0 66410 0 33637 0 20457 0 388802 0 0 0 ANDERSON DO TRENT D PHYSICIAN 244884 0 25000 0 1327 0 3440 0 28270 0 302921 0 0 0 JESKE MD ROBERT D PHYSICIAN 102733 118830 0 44000 284 345 0 11797 12276 17429 115293 192401 0 0 RENELT MD JOHN A PHYSICIAN 238681 0 0 0 155226 0 28511 0 31955 0 454373 0 0 0 SCHWEND DO PHILLIP P PHYSICIAN 228014 0 0 0 34993 0 39236 0 26677 0 328920 0 0 0 BROWN MARK C FMR COO 0 150723 0 0 0 25 0 4734 0 29113 0 184595 0 0 PART I, LINE 1A THE PERSONAL SERVICES THAT WERE PROVIDED ARE INCOME TAX PREPARATION SERVICES THAT, IN ACCORDANCE WITH MAYO POLICY, ARE AVAILABLE TO MAYO CLINIC VOTING/CONSULTING STAFF. SEVERAL OF THE CURRENT AND FORMER OFFICERS, DIRECTORS, AND KEY EMPLOYEES LISTED ON THIS RETURN RECEIVED THIS SERVICE, WHICH WAS TREATED AS TAXABLE COMPENSATION TO THE INDIVIDUALS. PART I, LINE 3 THE FILING ORGANIZATION RELIED ON A RELATED ORGANIZATION FOR ESTABLISHING THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. SEE CORE 990 PART VI SECTION B LINE 15 FOR FURTHER INFORMATION REGARDING THE PROCESS UTILIZED. PART I, LINES 4B-C THIS ENTITY OR ITS AFFILIATE HAS A SUPPLEMENTAL RETIREMENT PLAN (SRP) DESIGNED TO ROUGHLY APPROXIMATE AN EXTENSION OF THE BENEFITS UNDER THE MAYO PENSION PLAN TO INCOME ABOVE THE INTERNAL REVENUE CODE QUALIFIED PLAN LIMIT IN SECTION 401(A)(17). STARTING JANUARY 1, 2011, ALL SRP BENEFITS ARE PAID AS AN ANNUAL TAXABLE CASH PAYMENT. THE FOLLOWING INDIVIDUALS RECEIVED A PAYMENT FROM THE SUPPLEMENTAL RETIREMENT PLAN. AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III). ADAMSON M.D., STEVEN C. $11,647 AGERTER M.D., DAVID C. $49,966 KOCH, MARK B. $14,770 RENELT M.D., JOHN A. $ 5,237 SPANO M.D., DENNIS C. $42,555 WITT M.D., THOMAS J. $38,983 UNDER MAYO CLINIC'S ROYALTY SHARING POLICY, INVENTORS, INCLUDING LISTED PERSONS, ARE ENTITLED TO SHARE IN A PORTION OF ROYALTIES RECEIVED BY MAYO INCLUDING INSTANCES WHERE SUCH ROYALTIES ARE IN THE FORM OF EQUITY-BASED INSTRUMENTS SUCH AS STOCK, WARRANTS, OR PARTNERSHIP INTERESTS. PART II: COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. RENELT MD JOHN A EMPLOYEE SIGNING BONUS X 50000 5000 0 1 1 5000 LAURA S MARQUARDT EMPLOYMENT 64309 COMPENSATION PAID TO DAUGHTER OF BOARD OFFICER, SUSAN M. STIENE 0 LISA J GRUBER EMPLOYMENT 38793 COMPENSATION PAID TO SPOUSE OF BOARD MEMBER, JOHN GRUBER 0 MAUREEN T SULLIVAN-SPANO EMPLOYMENT 11856 COMPENSATION PAID TO SPOUSE OF BOARD OFFICER/MEMBER, DENNIS C. SPANO, M.D. 0 FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUAL IS EMPLOYED BY A RELATED ORGANIZATION: JESKE M.D., ROBERT D. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS WHO ARE ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: KOCH, MARK B. TARASOVITCH, JAMES J. THE FOLLOWING INDIVIDUAL IS EMPLOYED BY A RELATED ORGANIZATION: TARASOVITCH, JAMES J. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL WHO IS ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: KOCH, MARK B. THE FOLLOWING INDIVIDUALS ARE EMPLOYED BY A RELATED ORGANIZATION: KEENAN, AARON. WILKINSON M.D., JOHN M. PARKS, DOUGLAS A. GUDGELL, STEPHEN F. AGERTER M.D., DAVID C. RESULTING IN A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUAL WHO IS ASSOCIATED WITH THE RELATED ORGANIZATION AS AN OFFICER, DIRECTOR, OR TRUSTEE: KOCH, MARK B. FORM 990, PART VI, SECTION A, LINE 3 MAYO CLINIC, MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH, AND OTHER RELATED COMPANIES PROVIDE MANAGEMENT SERVICES TO THE ENTIRE SYSTEM OF ENTITIES. SINCE THE ENTITIES ARE RELATED ORGANIZATIONS, COMPENSATION FOR THE OFFICERS, DIRECTORS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES HAS BEEN DISCLOSED IN PART VII AND SCHEDULE J AS REQUIRED. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE CORPORATE MEMBER IS MAYO CLINIC. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER ELECTS THE GOVERNING BODY. ONE MEMBER IS ELECTED FROM A SLATE OF NOMINEES PROVIDED BY THE CITY COUNCIL OF LAKE CITY. FORM 990, PART VI, SECTION A, LINE 7B THE BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS DEBT, AMENDMENT OF THE BYLAWS, MERGERS, AND NEW SERVICES. AMENDMENTS OF THE ARTICLES OF INCORPORATION OR BYLAWS MUST BE APPROVED BY THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 8B THE FILING ORGANIZATION HAS A PHYSICIAN COMPENSATION COMMITTEE, A DELEGATED COMMITTEE OF THE BOARD, THAT MAKES RECOMMENDATIONS TO THE BOARD OF DIRECTORS. THE COMMITTEE HAS NO AUTHORITY TO ACT ON BEHALF OF THE BOARD, THEREFORE, THERE IS NO DOCUMENTATION FOR PART VI, SECTION A, LINE 8B. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY MAYO CORPORATE TAX WITH ASSISTANCE FROM SITE ACCOUNTING STAFF. THE TAX RETURN GOES THROUGH TWO LEVELS OF REVIEW WITHIN THE CORPORATE TAX UNIT. IT IS THEN REVIEWED BY THE REGION CHIEF FINANCIAL OFFICER AND FINANCE DIRECTOR, ALONG WITH SITE FINANCE STAFF. A COPY OF THE FORM 990 IS THEN PROVIDED TO EACH MEMBER OF THE FILING ORGANIZATION'S GOVERNING BODY VIA US MAIL, E-MAIL, OR DISTRIBUTION AT A BOARD MEETING. ALL QUESTIONS ARE ADDRESSED PRIOR TO FILING THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C MAYO CLINIC AND ITS AFFILIATES HAVE A COMPREHENSIVE CONFLICT OF INTEREST POLICY APPLICABLE TO ALL OF THE AFFILIATED ENTITIES AND TO ALL DIRECTORS, OFFICERS, AND EMPLOYEES OF THOSE ENTITIES. ALL CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES WHO WE ANTICIPATE WILL BE LISTED ON A FORM 990 ARE ASKED TO COMPLETE AN "ANNUAL TAX AND COMPLIANCE DISCLOSURE" FORM. THIS INFORMATION IS REVIEWED BY BOTH THE CORPORATE TAX DEPARTMENT AND THE OFFICE OF CONFLICT OF INTEREST REVIEW. ALL DISCLOSURES OF CURRENT OR PROPOSED ACTIVITY THAT REQUIRE ACTION UNDER THE POLICY ARE THE SUBJECT OF ONGOING REVIEW AND ACTION THROUGH THE OFFICE OF CONFLICT OF INTEREST REVIEW AND THE CONFLICT OF INTEREST REVIEW BOARD. INVOLVED INDIVIDUALS ARE INFORMED OF ALL REQUIRED ACTION. MANY TYPES OF RELATIONSHIPS THAT COULD CREATE CONFLICTS OF INTEREST ARE PROHIBITED. OTHER TYPES OF RELATIONSHIPS ARE PERMITTED SUBJECT TO COMPLIANCE WITH THE MANAGEMENT PLAN ESTABLISHED BY THE CONFLICT OF INTEREST REVIEW BOARD. A COMMON MANAGEMENT STRATEGY FOR PERMITTED ACTIVITIES IS TO REQUIRE BILATERAL RECUSAL AND APPROPRIATE DOCUMENTATION IN THE MINUTES OF MAYO CLINIC (AND/OR AFFILIATE) AND THE OUTSIDE ENTITY. ADDITIONAL CONFLICT OF INTEREST POLICIES AND PROCEDURES EXIST FOR CERTAIN ENTITIES CONCERNING RESEARCH CONTRACTS AND OTHER TYPES OF POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 THE FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC AND ITS AFFILIATES HAVE A COORDINATED PROCESS FOR REVIEWING AND APPROVING COMPENSATION AND BENEFITS FOR PHYSICIANS, EXECUTIVE AND SENIOR ADMINISTRATIVE LEADERSHIP, ALONG WITH ALLIED HEALTH STAFF. IN ADDITION TO ANY REVIEW AND APPROVAL THAT MAY TAKE PLACE AT THE LOCAL ENTITY OR REGIONAL LEVEL, THE FOLLOWING INDEPENDENT APPROVAL PROCESS OCCURS ANNUALLY PRIOR TO IMPLEMENTATION OF THE RESPECTIVE COMPENSATION INCREASE. THE SALARIES AND BENEFIT PROGRAMS OF THE CHIEF EXECUTIVE OFFICER (CEO) AND THE CHIEF ADMINISTRATIVE OFFICER (CAO) WERE REVIEWED AND APPROVED BY THE PROCESS DESCRIBED BELOW FOR SENIOR ADMINISTRATIVE LEADERSHIP. THE COMPENSATION AND BENEFIT PROGRAMS FOR SENIOR ADMINISTRATIVE LEADERSHIP FOR ALL CAMPUSES, INCLUDING THE MAYO CLINIC HEALTH SYSTEM LOCATIONS, ARE REVIEWED AND APPROVED BY THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE. THE MAYO CLINIC BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE IS COMPRISED OF NINE OF THE EXTERNAL INDEPENDENT MEMBERS OF THE MAYO CLINIC BOARD OF TRUSTEES. THIS GROUP REVIEWS AND APPROVES THE COMPENSATION AND BENEFIT PROGRAMS FOR PHYSICIANS FROM ALL CAMPUSES, AS WELL AS CERTAIN SENIOR ADMINISTRATIVE AND EXECUTIVE LEADERSHIP (INCLUDING ALL PERSONS BELIEVED TO BE DISQUALIFIED PERSONS). THIS PROCESS ESTABLISHES ACCEPTABLE RANGES FOR VARIOUS POSITIONS, LEVELS, AND SPECIALTIES. THE COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE FILING ORGANIZATION'S GOVERNING DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST AND ALSO ON THE MAYOCLINIC.ORG WEBSITE. THE FILING ORGANIZATION IS A HOSPITAL AFFILIATED WITH MAYO CLINIC. AS SUCH, MAYO CLINIC'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO THE FILING ORGANIZATION'S FORM 990 AND WOULD BE AVAILABLE UPON REQUEST OF THE FORM 990. FORM 990, PART IX, LINE 11G I/C PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 2,605,138. MANAGEMENT AND GENERAL EXPENSES 5,282,639. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,887,777. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,482,503. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,482,503. FORM 990, PART XI, LINE 9: RELIEVE CURRENT AND LONG TERM OUTSTANDING PLEDGE RECEIVABLES -3,000. FILING OF CERTAIN FOREIGN FORMS DISCLOSURE STATEMENT RELATED TO FORMS 5713: FORM 5713 HAS BEEN FILED BY THE FOLLOWING MEMBERS OF THE CONTROLLED GROUP: MAYO CLINIC (EIN: 41-6011702) MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH (EIN: 41-1506440) MAYO CLINIC ARIZONA (EIN: 86-0800150) MAYO CLINIC JACKSONVILLE (EIN: 59-3337028) DISCLOSURE STATEMENT RELATED TO FORMS 5471: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 4 AND 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCS). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. TAXPAYER NAME: MAYO CLINIC ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 5471 WAS FILED: 41-6011702 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED TAXPAYER NAME: MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 5471 WAS FILED: 41-1506440 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED DISCLOSURE STATEMENT RELATED TO FORMS 8865: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 8865, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN PARTNERSHIPS, AS A CATEGORY 2 AND 3 FILER. THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 8865 FOR THESE PARTNERSHIPS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. TAXPAYER NAME: MAYO CLINIC ADDRESS: 200 FIRST STREET SW, ROCHESTER, MN 55905 ID NUMBER OF U.S. TAX RETURN WITH WHICH FORM 8865 WAS FILED: 41-6011702 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(C)(3) 7 MCHS--CHIPPEWA VALLEY INC 1 CHARTERHOUSE INC 200 FIRST STREET SW ROCHESTER MN 55905 411405254 RETIREMENT LIVING CENTER MN 501(C)(3) 9 MAYO CLINIC 1 DESTINATION MEDICAL CENTER EDA 50 SOUTH SIXTH STREET SUITE 1500 MINNEAPOLIS MN 554021498 464893585 ECONOMIC DEVELOPMENT MN 501(C)(3) 11-I MAYO CLINIC 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(C)(3) 9 MFMER 1 LUTHER LAKESIDE APARTMENTS INC PO BOX 1510 EAU CLAIRE WI 54702 391409024 LOW INCOME HOUSING FOR ELDERLY WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - CLINIC MN 501(C)(3) 9 N/A 1 MAYO CLINIC ARIZONA 13400 EAST SHEA BOULEVARD SCOTTSDALE AZ 85259 860800150 HOSPITAL AND CLINIC AZ 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC FLORIDA (A NONPROFIT CORPORATION) 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 590714831 HOSPITAL FL 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MAYO CLINIC HOSPITAL -- ROCHESTER 200 FIRST STREET SW ROCHESTER MN 55905 410944601 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MAYO CLINIC JACKSONVILLE 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 593337028 PATIENT CARE - CLINIC FL 501(C)(3) 7 MAYO CLINIC 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 200 FIRST STREET SW ROCHESTER MN 55905 411506440 CHARITABLE, EDUCATIONAL & SCIENTIFIC ACTIVITIES MN 501(C)(3) 9 MAYO CLINIC 1 MAYO KLINIK STIFTUNG 60486 FRANKFURT AM MAIN FRANKFURT GM FUNDRAISING FOUNDATION GM MFMER 1 MCHS IN WAYCROSS INC 1900 TEBEAU STREET WAYCROSS GA 31501 581667166 HOSPITAL GA 501(C)(3) 3 MAYO CLINIC JACKSONVILLE 1 MCHS--ALBERT LEA AND AUSTIN 1000 FIRST DRIVE NW AUSTIN MN 55912 411404075 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--AUSTIN FOUNDATION 1000 FIRST DRIVE NW AUSTIN MN 55912 300107471 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--ALBERT LEA AND AUSTIN 1 MCHS--CANNON FALLS 32021 COUNTY ROAD 24 BLVD CANNON FALLS MN 55009 204156428 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--CHIPPEWA VALLEY INC 1501 THOMPSON STREET BLOOMER WI 54724 390980343 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--EAU CLAIRE CLINIC INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391735831 PATIENT CARE - CLINIC WI 501(C)(3) 3 MAYO CLINIC 0 MCHS--EAU CLAIRE FOUNDATION INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391633407 GRANTMAKING FOUNDATION WI 501(C)(3) 11-I MCHS--EAU CLAIRE CLINIC INC 0 MCHS--EAU CLAIRE HOSPITAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 390813418 HOSPITAL WI 501(C)(3) 3 MAYO CLINIC 1 MCHS--FAIRMONT 800 MEDICAL CENTER DRIVE PO BOX 800 FAIRMONT MN 56031 410760836 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--FRANCISCAN HEALTHCARE FOUNDATION INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391186647 FUNDRAISING FOUNDATION WI 501(C)(3) 7 MCHS--FRANCISCAN HEALTHCARE INC 1 MCHS--FRANCISCAN HEALTHCARE FOUNDATION-SPARTA INC 310 WEST MAIN STREET SPARTA WI 54656 391423234 FUNDRAISING FOUNDATION WI 501(C)(3) 9 MCHS--FRANCISCAN HEALTHCARE INC 1 MCHS--FRANCISCAN HEALTHCARE INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391411999 HEALTHCARE SYSTEM PARENT WI 501(C)(3) 11-I MAYO CLINIC 1 MCHS--FRANCISCAN MEDICAL CENTER INC 700 WEST AVE SOUTH LA CROSSE WI 54601 390806374 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--FRANCISCAN HEALTHCARE INC 1 MCHS--HOME HEALTH & HOSPICE INC PO BOX 2060 EAU CLAIRE WI 54702 391491516 HOME HEALTH AND HOSPICE CARE WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--LAKE CITY 500 WEST GRANT STREET LAKE CITY MN 55041 411906820 HOSPITAL MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--MANKATO 1025 MARSH STREET MANKATO MN 56002 411236756 HOSPITAL AND CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--MANKATO HEALTH CARE FOUNDATION 1025 MARSH STREET MANKATO MN 56002 411663357 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--MANKATO 1 MCHS--NEW PRAGUE 301 SECOND STREET NE NEW PRAGUE MN 56071 410723639 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--NORTHLAND INC 1222 EAST WOODLAND AVENUE BARRON WI 54812 390920634 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--OAKRIDGE INC 13025 EIGHTH STREET PO BOX 70 OSSEO WI 54758 391029430 HOSPITAL AND CLINIC WI 501(C)(3) 3 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--OWATONNA 134 SOUTHVIEW ST OWATONNA MN 55060 411862132 PATIENT CARE - CLINIC MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--RED CEDAR INC 2321 STOUT ROAD MENOMONIE WI 54751 510190875 HOSPITAL AND CLINIC WI 501(C)(3) 3 MAYO CLINIC 1 MCHS--RED WING 701 HEWITT BOULEVARD RED WING MN 55066 411713783 PATIENT CARE SERVICES MN 501(C)(3) 3 MAYO CLINIC 1 MCHS--SPRINGFIELD 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--ST JAMES 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 410797368 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MCHS--ST JAMES HEALTH CARE FOUNDATION 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 411444129 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MCHS--ST JAMES 1 MCHS--SUPPORTIVE HOMECARE INC PO BOX 2060 EAU CLAIRE WI 54702 391686673 HOME HEALTH CARE WI 501(C)(3) 9 MCHS--EAU CLAIRE HOSPITAL INC 1 MCHS--WASECA 501 NORTH STATE STREET WASECA MN 56093 363606405 HOSPITAL AND CLINIC MN 501(C)(3) 3 MCHS--MANKATO 1 MILES AND SHIRLEY FITERMAN ENDOWMENT FUND FOR DIGESTIVE DISEASES 200 FIRST STREET SW ROCHESTER MN 55905 412020392 SUPPORT RESEARCH, PRACTICE & EDUCATION MN 501(C)(3) 11-I MAYO CLINIC 1 POVERELLO FOUNDATION 200 FIRST STREET SW ROCHESTER MN 55905 411494881 FUNDRAISING FOUNDATION MN 501(C)(3) 7 MAYO CLINIC HOSPITAL - ROCHESTER 1 FRANKLIN HEATING STATION 119 THIRD ST SW ROCHESTER MN 55902 410264830 UTILITY MN N/A LATIGO PETROLEUM LLC PO BOX 14230 ODESSA TX 79768 364767494 OIL & GAS EXPLORATION DE N/A PHYSICIAN SOFTWARE SYSTEMS LLC 3333 WARRENVILLE ROAD SUITE 200 LISLE IL 60532 453414836 HEALTHCARE RELATED SOFTWARE IL N/A WATERSHED CAP INSTL PRTNRS III LP ONE MARITIME PLAZA SUITE 1525 SAN FRANCISCO CA 94111 462982848 INVESTMENT ACTIVITIES DE N/A BWL HOLDINGS INC 1209 ORANGE STREET WILMINGTON DE 19801 472413749 OIL & GAS EXPLORATION DE N/A C 1 AMBIENT CLINICAL ANALYTICS INC 221 1ST AVE SW SUITE 202 ROCHESTER MN 55902 800928405 SOFTWARE DE N/A C 1 CAVALRY CLO III LTD PO BOX 1093 GT QUEENSGATE HOUSE S GRAND CAYMAN CJ INVESTMENT ACTIVITIES CJ N/A C 1 CAVALRY CLO IV LTD PO BOX 1093 GT QUEENSGATE HOUSE S GRAND CAYMAN CJ INVESTMENT ACTIVITIES CJ N/A C 1 GMO GLOBAL BOND INVESTMENT FUND 78 SIR JOHN ROGERSONS QUAY DUBLIN 2 EI OTHER FINANCIAL INVESTMENT ACTIVITIES EI N/A 1 HEALTH TRADITION HEALTH PLAN 1808 EAST MAIN STREET ONALASKA WI 54650 391545987 MEDICAL SERVICES COMPANY WI N/A C 1 LOBSS NETWORK SUPPORT 2002 INC 200 FIRST STREET SW ROCHESTER MN 55905 481276150 ADMINISTRATIVE SERVICES MN N/A C 1 MAYO CLINIC GBS MAURITIUS 2ND FLOOR EBENE MEWS 57 EBENE CYBERCITY MP HEALTHCARE MANAGEMENT MP N/A C 1 MAYO CLINIC SUPPORT SERVICES TEXAS 200 FIRST STREET SW ROCHESTER MN 55905 471751102 HEALTH SERVICES TX N/A C 1 MAYO HOLDING COMPANY 200 FIRST STREET SW ROCHESTER MN 55905 411578020 HOLDING COMPANY MN N/A C 1 MAYO INSURANCE COMPANY LTD 200 FIRST STREET SW ROCHESTER MN 55905 SELF INSURANCE POOL CJ N/A C 1 MCHS--DECORAH CLINIC PHYSICIANS 907 MONTGOMERY STREET DECORAH IA 52101 411711329 PATIENT CARE - CLINIC IA N/A C 1 MCHS--PHARMACY & HOME MEDICAL INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 391528920 PHARMACY SERVICES WI N/A C 1 MMSI INC 21 FIRST STREET SW ROCHESTER MN 55905 411547003 THIRD PARTY ADMINISTRATION SERVICES MN N/A C 1 RESOUNDANT INC 221 1ST AVE SW ROCHESTER MN 55902 461661978 MANUFACTURING MEDICAL DEVICE COMPONENT MN N/A C 1 ROCHESTER AIRPORT COMPANY ROUTE 2 ROCHESTER MN 55902 410506870 AIRPORT MANAGEMENT MN N/A C 1 SATILLA HEALTHNET INC 1900 TEBEAU STREET WAYCROSS GA 31501 582151076 HEALTH SERVICES GA N/A C 1 SUPERBLOCK 3 PROPERTY OWNERS ASSOCIATION 13400 E SHEA BLVD SCOTTSDALE AZ 85259 860870505 COMMERCIAL PROPERTY OWNERS ASSOCIATION AZ N/A C 1 THE STABILE BUILDING OWNERS' ASSOCIATION 200 FIRST STREET SW ROCHESTER MN 55905 208994499 COMMERCIAL PROPERTY OWNERS ASSOCIATION MN N/A C 1 CHARITABLE LEAD TRUST CHARITABLE TRUST CA N/A T 1 PERPETUAL TRUST CHARITABLE TRUST ND N/A T 1 PERPETUAL TRUST CHARITABLE TRUST AZ N/A T 1 PERPETUAL TRUST CHARITABLE TRUST LA N/A T 1 PERPETUAL TRUST (2) CHARITABLE TRUST MA N/A T 1 PERPETUAL TRUST CHARITABLE TRUST MO N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST AZ N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST CO N/A T 1 CHARITABLE REMAINDER TRUST (9) CHARITABLE TRUST FL N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST LA N/A T 1 CHARITABLE REMAINDER TRUST (73) CHARITABLE TRUST MN N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST NC N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST NM N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST NV N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST NY N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST TX N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST WI N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST CO N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST IL N/A T 1 CHARITABLE REMAINDER TRUST CHARITABLE TRUST MI N/A T 1 CHARITABLE REMAINDER TRUST (70) CHARITABLE TRUST MN N/A T 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 1 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH P 16462192 GAAP MCHS-ALBERT LEA AND AUSTIN P 1688451 GAAP MCHS-CANNON FALLS S 276635 GAAP MCHS-RED WING R 1056847 GAAP MMSI INC R 2982435 GAAP MMSI INC S 2324276 GAAP