2014-08-04T09:13:16-05:00 2013-09-30 420714325 MCGLADREY LLP 227 W FIRST ST STE 700 DULUTH MN 558021919 990 2012-10-01 410724029 RIVERVIEW HEALTHCARE ASSOCIATION RIVE 2182819200 323 SOUTH MINNESOTA STREET CROOKSTON MN 56716 CARRIE MICHALSKI 2182819200 2014-07-16 1 MARY BETH SANTORI P00023783 2187275025 2012 2015-11-30 17:44:51Z CARRIE MICHALSKI 323 SOUTH MINNESOTA STREET CROOKSTON MN 56716 51009212 0 X RIVERVIEWHEALTH.ORG X 1898 MN RIVERVIEW HEALTH PROVIDES WORLD-CLASS HEALTHCARE THROUGH A CULTURE OF EXCELLENCE THAT PROVIDES ACCESS TO OUR COMMUNITY FOR ALL HEALTHCARE NEEDS. SERVING AS AN ADVOCATE FOR OUR COMMUNITY, PATIENTS, MEDICAL STAFF AND EMPLOYEES. 10 9 605 110 0 0 527014 265506 53488649 50457288 62976 99050 134266 142937 54212905 50964781 0 0 0 0 30652076 29824869 0 0 0 23789102 24341128 54441178 54165997 -228273 -3201216 42352362 38420464 24213883 23486995 18138479 14933469 X WE DELIVER A HEALTHCARE EXPERIENCE THAT CONSISTENTLY EXCEEDS PATIENTS EXPECTATIONS THROUGH:EXCEPTIONAL PEOPLE- OUR PEOPLE ARE OUR FOUNDATION. WE EMPLOY TRUSTED, DEDICATED PROFESSIONALS WHO SERVE WITH COMPASSION, EMPATHY AND RESPECT. EXCEPTIONAL CARE- OUR PATIENTS ARE OUR FOCUS. WE BUILD RELATIONSHIPS TO DELIVER PERSONALIZED CARE. EXCEPTIONAL OUTCOMES- OUR PASSION IS TO ENHANCE LIVES. WE ENGAGE IN THE BEST PRACTICES TO HEAL PEOPLE AND PROMOTE HEALTHY COMMUNITIES. 0 0 40407074 45702066 HOSPITAL AND CLINIC - RIVERVIEW HEALTHCARE DIRECTLY PROVIDES OR SUPPORTS THE PROVISION OF A CONTINUUM OF QUALITY, ACCESSIBLE AND COST EFFECTIVE SERVICES FOCUSED ON THE NEEDS OF INDIVIDUALS. RIVERVIEW STRIVES TO MEET AREA MEDICAL NEEDS AND IMPROVE THE PHYSICAL AND MENTAL WELLBEING FOR PEOPLE OF THE AREA. THE HOSPITAL IS A MODERN 25 BED ACUTE CARE CRITICAL ACCESS HOSPITAL. HOSPITAL ADMISSIONS 1,019, PATIENT DAYS 3,673, OUTPATIENT VISITS 37,417, SURGERY 2,381, AND ER PATIENTS 6,852. THE CLINICS PROVIDE A WIDE RANGE OF SERVICES INCLUDING FAMILY PRACTICE DOCTORS AND SPECIALTY DOCTORS. CLINIC PATIENT VISITS 31,107. 4377819 2696907 NH CARE CENTER, HOME HEALTH AND ASSISTED LIVING - RIVERVIEW CARE CENTER PROVIDES STIMULATING DAILY ACTIVITIES FOR ITS RESIDENTS IN AN ENJOYABLE ENVIRONMENT AND A CARING ATMOSPHERE WHERE ALL RESIDENTS ARE TREATED WITH THE UTMOST DIGNITY. THE MEMORY CARE UNIT PROMOTES A CALM & THERAPEUTIC ATMOSPHERE. RIVERVIEW CARE CENTER IS A 24-BED FACILITY. NURSING HOME ADMISSIONS 8 AND RESIDENT DAYS 8,040. RIVERVIEW HOME CARE IS A FULL SERVICE HOME CARE AGENCY PROVIDING 24 HR ACCESS TO ON CALL NURSES, ROUTINE SERVICE ON WEEKENDS AND HOLIDAYS AND A FULL RANGE OF THERAPY SERVICES. HOME HEALTH PATIENTS 1,372 AND PATIENT VISITS 6,722. RIVERVIEW ASSISTED LIVING PROVIDES SERVICE TO RESIDENTS IN CROOKSTON. ASSISTANCE FOR THOSE UNABLE TO LIVE ALONE WITHOUT AID INCLUDES HOUSEKEEPING, HELP DRESSING, BATHING, PREPARING MEALS, MEDICATION SET-UP AND MANY OTHER SERVICES. ASSISTED LIVING PATIENTS 294 AND PATIENT VISITS 4,466. 2913612 2058315 RIVERVIEW RECOVERY CENTER PROVIDES A DAY TREATMENT AND OUTPATIENT TREATMENT PROGRAM EFFECTIVE FOR THE ADULT WHO IS ABUSING OR DEPENDENT ON ONE OR MORE MOOD-ALTERING CHEMICALS. THE RECOVERY CENTER OPERATES CLINICS IN CROOKSTON, EAST GRAND FORKS, THIEF RIVER FALLS & ROSEAU MINNESOTA. RECOVERY CENTER OUTPATIENT VISITS 4,820. 47698505 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 227 0 1 605 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 0 1 1 0 MN X BETTY ARVIDSON 2182819756 323 SOUTH MINNESOTA ST CROOKSTON MN 56716 X JENNY AMON 1.00 X 0 0 0 ROBIN BREKKEN 2.00 X X 0 0 0 DR COLIN FENNELL 41.00 X 611754 0 34064 TRENT FISCHER 1.00 X X 0 0 0 MATTHEW FORGIT 1.00 X 0 0 0 MICHAEL MOORE 1.00 X 0 0 0 ANDREW SVEC 2.00 X X 0 0 0 SUE WESTROM 2.00 X X 0 0 0 MICHELLE COTE 1.00 X 0 0 0 ANDY OMAN 1.00 X 0 0 0 ROSS MATLACK 40.00 X 241213 0 30667 CARRIE MICHALSKI 40.00 X 130046 0 23967 BILL BENNETT 40.00 X 143461 0 11933 BETTY ARVIDSON 40.00 X 86445 0 6284 SANDY BOICE 40.00 X 118907 0 12022 JEAN TATE 40.00 X 105100 0 12869 DR IDATONYA AFONYA 40.00 X 334826 0 31880 CHRIS BRUGGEMAN 40.00 X 78298 0 5443 LANCE NORMAN 40.00 X 109896 0 8628 DR OLATUBOSUN FASHORO 40.00 X 455614 0 32103 DR MIRZA BAIG 40.00 X 314432 0 31840 DR ERIK KANTEN 40.00 X 490839 0 31173 DR STEVEN SCHULTZ 40.00 X 327706 0 29647 DR KARI WESSMAN 40.00 X 333873 0 13335 3882410 0 315855 31 0 1 0 SEIMENS FINANCIAL PO BOX 2083 CAROL STREAM IL 60132 XRAY IMAGING 1149241 NEW HORIZON FOODS PO BOX 860246 MINNEAPOLIS MN 55486 FOOD 1128972 WAPITI MEDICAL GROUP PO BOX 523 MILBANK SD 57252 ER PHYSICIANS 1095615 UNIVERSAL HOSPITAL SERVICES SDS 12-0940 PO BOX 86 MINNEAPOLIS MN 55486 BIO-MEDICAL 693878 SHARED MEDICAL TECHNOLOGY 202 WEST NEWTON ST RICE LAKE WI 54868 XRAY IMAGING 365934 13 3125 30074 8355 223952 265506 RIVERVIEW HOSPITAL 621990 37739022 37739022 PHYSICIAN CLINICS 621110 7068183 7068183 GLENMORE RECOVERY CENTER 624310 2058315 2058315 RIVERVIEW CARE CENTER 623000 1820240 1820240 HOME HEALTH & ASSISTED 621610 876667 876667 894861 894861 50457288 60202 60202 83279 44431 38848 38848 38848 CAFE SALE 722210 142937 142937 142937 50964781 50457288 0 241987 2045229 1017754 1027475 22424480 20811309 1613171 972871 904285 68586 2856059 2606908 249151 1526230 1366676 159554 59085 12400 46685 141521 2625 138896 1028492 1028492 575097 575097 875312 875312 2266075 2266075 261407 261407 NURSING SERVICE SUPPLIE 8285890 8285890 OTHER MEDICAL SUPPLIES 5745836 5745836 GENERAL SERVICES SUPPLI 2022676 2022676 PROVISION FOR DOUBTFUL 1780759 1780759 1298978 1298978 54165997 47698505 6467492 0 2139 1893 1680811 3570544 14493312 10544601 424833 277139 1194662 1132324 155307 130944 46611744 29874661 18721984 16737083 4280558 5052864 1398756 973072 42352362 38420464 7741789 7192575 0 514461 14365000 13940000 11318 5144 1547576 1404165 548200 430650 24213883 23486995 X 18138479 14933469 18138479 14933469 42352362 38420464 -3201216 -3794 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 696 696 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: RIVERVIEW HEALTHCARE ASSOCIATION PAYS DUES TO CERTAIN ORGANIZATIONS RELATED TO THE INDUSTRY WHICH HAVE LOBBYING EXPENSES. THE AMOUNT LISTED IS THE PERCENTAGE OF THE DUES PAID THAT WERE USED FOR LOBBYING. 0 1 X 881779 982 31628 788 913601 815153 2205 65454 1033 881779 815243 3994 -4039 45 815153 778984 816 38940 3497 815243 770200 3221 18491 12928 778984 1.00000 0 1 1 813932 813932 26014352 15815704 10198648 13325572 10492613 2832959 6457888 3566344 2891544 16737083 WORKERS COMPENSATION 430650 430650 X 49404115 -3794 -1556872 -1560666 50964781 0 50964781 52490597 105359 105359 52385238 1780759 1780759 54165997 PART IV, LINE 2B: THE HOSPITAL IS A CUSTODIAN OF FUNDS FOR RESIDENTS. THE HOSPITAL HOLDS THESE FUNDS FOR PURCHASES MADE BY THE RESIDENTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ASSOCIATION'S ENDOWMENT INCLUDES FUNDS DESIGNATED BY THE BOARD OF DIRECTORS TO FUNCTION AS ENDOWMENTS. THESE FUNDS ARE MAINTAINED IN THE FOUNDATION. THE FUNDS ARE USED TO PROVIDE TO THE RESIDENTS OF ITS SERVICE AREA, QUALITY HEALTHCARE AND RELATED HEALTH SERVICES, EDUCATION, RESEARCH, PROMOTION OF HEALTH AND OTHER ACTIVITIES IN THE COMMUNITY. THE CONTRIBUTIONS RAISED BY THE FOUNDATION ARE GRANTED TO THE RIVERVIEW HEALTHCARE ASSOCIATION TO PURCHASE MEDICAL EQUIPMENT AND SUPPLIES FOR PROMOTION OF HEALTHCARE IN THE COMMUNITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: NOT-FOR-PROFIT ORGANIZATIONS MAY BECOME SUBJECT TO INCOME TAXES IF QUALIFICATION AS A TAX-EXEMPT ENTITY CHANGES, IF UNRELATED BUSINESS INCOME IS GENERATED, AND IN CERTAIN OTHER INSTANCES. NOT-FOR-PROFIT ORGANIZATIONS ARE REQUIRED TO ASSESS THE CERTAINTY OF THEIR TAX POSITIONS RELATED TO THESE MATTERS AND, IN SOME CASES, RECORD LIABILITIES FOR POTENTIAL TAXES, INTEREST AND PENALTIES ACCOMPANIED BY FOOTNOTE DISCLOSURES. THE ASSOCIATION HAS NOT IDENTIFIED ANY UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE THE ACCRUAL OF AN INCOME TAX PROVISION. GENERALLY, THE ASSOCIATION IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL OR STATE TAX AUTHORITIES FOR YEARS BEFORE 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: RIVERVIEW FOUNDATION REVENUE 223,887. PROVISION FOR DOUBTFUL RECEIVABLES -1,780,759. PART XII, LINE 2D - OTHER ADJUSTMENTS: RIVERVIEW FOUNDATION EXPENSES 105,359. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL RECEIVABLES 1,780,759. 1 1 1 X 1 X 230.000000000000 1 1 0 1 1 536539 536539 0.01020 7738564 7738564 0.14770 8275103 8275103 0.15790 89884 89884 0.00170 321935 321935 0.00610 10485324 7888718 2596606 0.04960 43800 43800 0.00080 10940943 7888718 3052225 0.05820 19216046 7888718 11327328 0.21610 1 1780759 118189 11411910 11419945 -8035 X 1 1 1 1 RIVERVIEW HOSPITAL

323 SOUTH MINNESOTA ST CROOKSTON MN 56716

X X X X RIVERVIEW HOSPITAL 1 1 X X X X X X X X 12 1 0 1 X X X X X X X X X 1 0 1 1 150.000000000000 1 230.000000000000 1 X X X X 1 1 X X X X 1 0 1 X 0 0 10 RIVERVIEW CLINICS CROOKSTON

323 SOUTH MINNESOTA ST CROOKSTON MN 56716

OUTPATIENT CLINIC RIVERVIEW CLINIC EAST GRAND FORKS

1428 CENTRAL AVE NE EAST GRAND FORKS MN 56721

OUTPATIENT CLINIC/REHAB RIVERVIEW CLINIC FERTILE

206 NORTH MILL ST FERTILE MN 56540

OUTPATIENT CLINIC RIVERVIEW CLINIC RED LAKE FALLS

PARK PLACE MALL RED LAKE FALLS MN 56750

OUTPATIENT CLINIC/REHAB RIVERVIEW CARE CENTER

323 SOUTH MINNESOTA ST CROOKSTON ND 56716

NURSING HOME RIVERVIEW HOME CARE

721 SOUTH MINNESOTA ST CROOKSTON MN 56716

HOME HEALTH RIVERVIEW RECOVERY CROOKSTON

23616 US HWY 2 SW CROOKSTON MN 56716

CHEMICAL DEPENDENCY RIVERVIEW RECOVERY THIEF RIVER FALLS

309 NORTH LEBREE AVE SUITE 10 THIEF RIVER FALLS MN 56701

CHEMICAL DEPENDENCY RIVERVIEW RECOVERY ROSEAU

216 CENTER ST WEST 101 ROSEAU MN 56751

CHEMICAL DEPENDENCY RIVERVIEW RECOVERY EAST GRAND FORKS

201 GATEWAY DRIVE NE SUITE 4 EAST GRAND FORKS MN 56721

CHEMICAL DEPENDENCY PART I, LINE 7: COSTS ARE CALCULATED USING FINANCIAL DATA AND THE COST TO CHARGE RATIO FROM THE AS FILED 2013 MEDICARE COST REPORT.(PART I, LINE 7E) COMMUNITY HEALTH SERVICES IS THE TOTAL COST OF ACTIVITIES TO IMPROVE COMMUNITY HEALTH IN THE FOLLOWING AREAS 1) PROVIDING COMMUNITY HEALTH EDUCATION WITH HEALTH LECTURES AND WORKSHOPS TO COMMUNITY GROUPS, HEALTH AND CAREER DAY FAIRS, FAMILY AND FRIENDS CPR CLASSES AND BY PROVIDING SPECIFIC DIAGNOSES (AUTISM) SUPPORT GROUPS 2) PROVIDING CLINICAL SERVICES SUCH AS FREE BLOOD PRESSURE AND CHOLESTEROL SCREENING AT HEALTH FAIRS 3) PROVIDING SUPPORT SERVICES LIKE ENROLLMENT ASSISTANCE IN PUBLIC PROGRAMS, MENTAL HEALTH SERVICE HOT-LINES AND BUS TRANSPORTATION VOUCHERS TO ENHANCE PATIENT ACCESS TO CARE. (PART I, LINE 7F) HEALTH PROFESSIONS EDUCATION IS THE COST OF OPERATING PROFESSIONAL EDUCATION AND TRAINING PROGRAMS FOR MEDICAL STUDENTS, NURSING STUDENTS, AND TECHNICIANS. SCHOLARSHIPS ARE ALSO OFFERED TO NON-EMPLOYEES FOR NURSING AND OTHER PROFESSIONAL EDUCATION.(PART I, LINE 7G) SUBSIDIZED HEALTH SERVICES INCLUDE COSTS FOR BILLED SERVICES THAT ARE SUBSIDIZED BY THE HEALTH CARE ORGANIZATION. CLINICAL PATIENT CARE SERVICES ARE PROVIDED DESPITE A NEGATIVE MARGIN BECAUSE THEY ARE NEEDED BY THE COMMUNITY. THE HOSPITAL'S SUBSIDIZED HEALTH SERVICES INCLUDE ANETHESIOLOGY, RESPIRATORY THERAPY, PHYSICAL THERAPY, CARDIAC REHAB, OCCUPATIONAL THERAPY, IMPLANTABLE DEVICES CHARGED TO PATIENTS, CLINIC, EMERGENCY, AND OBSERVATION BEDS.(PART I, LINE 7I) FINANCIAL CONTRIBUTIONS INCLUDE MONIES FOR SPONSORSHIPS AND IN-KIND SERVICES DONATED TO INDIVIDUALS OR THE COMMUNITY. THIS INCLUDES OVERHEAD EXPENSES OF SPACE DONATED TO NONPROFIT COMMUNITY GROUPS FOR MEETINGS (AA, BONE BUILDERS, ROTARY CLUB), DONATIONS OF MEDICAL SUPPLIES AND LINEN AND MEDICAL CARE PROVIDED AT A COMMUNITY EVENT. PART I, L7 COL(F): BAD DEBT EXPENSE FROM FINANCIAL STATEMENTS IS 1,780,759. PART II: N/A PART III, LINE 4: FROM FOOTNOTE 1 OF THE AUDITED FINANCIAL STATEMENTS - "PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT ORIGINAL CHARGE FOR THE SERVICE PROVIDED, LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS AND BY USING HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS. PATIENT RECEIVABLES ARE WRITTEN OFF WHENDEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED WHEN RECEIVED."WORKSHEET 2 RATIO OF PATIENT CARE COST TO CHARGES TO DETERMINE PERCENTAGE OF BAD DEBTS EXPENSE AT COST. DISCOUNT INFORMATION IS PROVIDED BY THE THIRD PAYOR (ACCORDING TO CONTRACTS) AND RECORDED FOLLOWING GAAP GUIDELINES. BAD DEBT EXPENSE IS DETERMINED ACCORDING TO OUR PAYMENT AND COLLECTION POLICY MANUAL BAD DEBT AMOUNTS ARE NOT INCLUDED IN COMMUNITY BENEFITS.ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY WAS DETERMINED BY TAKING THE BAD DEBT EXPENSE AND MULTIPLYING IT BY THE RATIO OF THE ORGANIZATION'S MEDICAID CONTRACTUAL ADJUSTMENTS TO THE TOTAL PATIENT SERVICE REVENUE AMOUNTS FROM THE MANAGEMENT LETTER. PART III, LINE 8: THE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND THUS IS REIMBURSED AT 101% OF COST. THE MEDICARE FEES FOR REIMBURSED SERVICES RESULTED IN NET REVENUE OF $419,318 AND ALLOWABLE COSTS OF $1,661,496 RESULTING IN A SHORTFALL OF $1,242,178. THE SHORTFALL IS THE RESULT OF UNREIMBURSED PROFESSIONAL CARE.THE HOSPITAL FOLLOWED MEDICARE'S PRESCRIBED METHODS OF DETERMINING COSTS PAYABLE UNDER TITLE XVIII (MEDICARE) IN COMPLETING ITS ANNUAL MEDICARE COST REPORT (COST REPORT) USING DATA AVAILABLE FROM THE INSTITUTION'S BASIC ACCOUNTS, AS USUALLY MAINTAINED, TO ARRIVE AT EQUITABLE AND PROPER PAYMENT FOR SERVICES. THE COST REPORT WAS COMPLETED USING THE HOSPITAL'S TRIAL BALANCE OF EXPENSES, AS WELL AS OTHER STATISTICAL AND FINANCIAL RECORDS MAINTAINED BY THE HOSPITAL. AS REQUIRED BY MEDICARE REGULATIONS, CERTAIN RECLASSIFICATIONS AND ADJUSTMENTS TO COSTS WERE INCLUDED IN THE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS.AFTER MEDICARE ALLOWABLE COSTS ARE DETERMINED, THE COST REPORT PROVIDES FOR THE STEP DOWN METHOD OF COST FINDING. THIS METHOD PROVIDES FOR ALLOCATING THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS, WHICH UTILIZE THE SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. AFTER ALL COSTS OF THE GENERAL SERVICE COST CENTERS HAVE BEEN ALLOCATED TO THE REMAINING COST CENTERS, THE TOTAL COSTS OF THESE REMAINING COST CENTERS ARE FURTHER DISTRIBUTED TO THE DEPARTMENTAL CLASSIFICATION TO WHICH THEY PERTAIN, E.G., HOSPITAL GENERAL INPATIENT ROUTINE, SUBPROVIDER, ANCILLARY, ETC.AFTER THE STEP-DOWN PROCESS, THE COST REPORT PROVIDES FOR THE APPORTIONMENT OF COSTS TO THE MEDICARE PROGRAM BASED ON A NUMBER OF DIFFERENT METHODOLOGIES INCLUDING PER PATIENT DAY, PER VISIT, AND PERCENTAGE OF CHARGES, AS MOST PREVALENT. MEDICARE COSTS AS DETERMINED BY THE COST REPORT METHODOLOGIES DESCRIBED PREVIOUSLY WERE UTILIZED TO COMPLETE THE APPLICABLE MEDICARE ALLOWABLE COSTS OF CARE FOR SCHEDULE H (FORM 990) PART III SECTION B LINE 6. PART III, LINE 9B: THROUGHOUT THE PAYMENT AND COLLECTION PROCESS, STAFF ATTEMPTS TO IDENTIFY TO THE EXTENT POSSIBLE, PATIENTS WHICH ARE WORTHY AND APPROPRIATE FOR CHARITY CONSIDERATION. THOSE ACCOUNTS TO BE CONSIDERED FOR CHARITY REDUCTIONS ARE ASKED TO COMPLETE A FINANCIAL DISCLOSURE FORM, WHICH WILL PROVIDE PERTINENT PATIENT FINANCIAL INFORMATION NECESSARY TO DETERMINE FINANCIAL NEED. REVIEW OF POTENTIAL CHARITY REQUESTS ARE PERFORMED DAILY BY THE FINANCIAL COORDINATOR AND CERTAIN RECOMMENDATIONS ARE FORWARDED TO THE CFO FOR SIGNATURE AND APPROVAL. ALL MINNESOTA RESIDENTS, UPON REQUEST WHO ARE UNINSURED WILL RECEIVE A PRIVATE PAY DISCOUNT DETERMINED BY THE INSURANCE COMPANY WITH WHICH RIVERVIEW HEALTH DOES THE GREATEST VOLUME. THE SOCIAL SERVICES DEPARTMENT OF RIVERVIEW HEALTHCARE WORK CLOSELY WITH THE STATE MEDICAID ELIGIBILITY PROGRAM TO ENSURE PATIENTS HAVE ACCESS TO AVAILABLE PROGRAMS. NON-INSURED PATIENTS ARE REFERRED TO THE STATE MEDICAID ELIGIBILITY PROGRAM FOR A PROBABILITY OF ELIGIBILITY ASSESSMENT. RIVERVIEW HOSPITAL PART V, SECTION B, LINE 3: OUR LEAD PERSON (CHIEF OPERATING OFFICER) GATHERED INFORMATION ELECTRONICALLY FROM THE FOLLOWING PERSONS IN THE COMMUNITY: POLK COUNTY PUBLIC HEALTH, NORTHWEST MENTAL HEALTH, POLK COUNTY SOCIAL SERVICES, WELLNESS COALITION, RIVERVIEW BOARD OF DIRECTORS, RIVERVIEW ASSOCIATION MEMBERS, AND CROOKSTON PUBLIC SCHOOLS. RIVERVIEW HOSPITAL PART V, SECTION B, LINE 5C: THE NEEDS ASSESSMENT IS AVAILABLE ON THE HOSPITAL'S WEBSITE AND IS AVAILABLE UPON REQUEST FROM THE HOSPITAL FACILITY. RIVERVIEW HOSPITAL PART V, SECTION B, LINE 12H: FAMILY SIZE RIVERVIEW HOSPITAL PART V, SECTION B, LINE 20D: EVERYONE IS CHARGED THE SAME GROSS AMOUNT, BUT THE DISCOUNT FOR UNDERINSURED IS DETERMINED BY USING THE LARGEST COMMERCIAL INSURANCE RATE. PART VI, LINE 2: THE HOSPITAL PERFORMED PATIENT SURVEYS AND HIRED CONSULTANTS THAT PERFORM SURVEYS AND STUDIES TO DETERMINE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: CHARITY CARE FORMS ARE HANDED OUT IN ADMITTING AND ALSO PLACED IN COLLECTION LETTERS. MEDICAID SERVICES INFORMATION IS AVAILABLE TO PATIENTS AT REGISTRATION. THE MULTI-DISCIPLINARY DISCHARGE PLANNING COMMITTEE MEETS DAILY AND PLANS THE DISCHARGE OF PATIENTS INCLUDING FINANCIAL PLANNING. REFER TO APPROPRIATE AGENCIES AND PROGRAMS FOR FINANCIAL AID WHEN THE PATIENT HAS NO HOSPITAL INSURANCE OR WHEN PATIENT/FAMILY RESOURCES ARE LIMITED OR DEPLETED. PART VI, LINE 4: RIVERVIEW HEALTH PRIMARY SERVICE AREA CONSISTS OF POLK & RED LAKE COUNTY WITH A POPULATION OF APPROXIMATELY 35,700. THE UNEMPLOYMENT RATE IS BELOW THE STATE LEVEL. THE MAJORITY OF WORKERS ARE EMPLOYED IN HEALTHCARE, MANUFACTURING OR FARMING. DESPITE A HIGHER RATE OF EMPLOYMENT, NEARLY 25 PERCENT OF HOUSEHOLDS EARN LESS THAN $25,000.00 PER YEAR COMPARED TO 20 PERCENT OF HOUSEHOLDS STATEWIDE. PART VI, LINE 5: COMMUNITY BUILDING ACTIVITIES ARE PROGRAMS AND ACTIVITIES THAT ARE DESIGNED TO ADDRESS ROOT CAUSES OF HEALTH PROBLEMS IN THE COMMUNITY. DISASTER READINESS, REDUCING THE AIR ENVIRONMENTAL HAZARDS, SHARPS DISPOSAL AND COMMUNITY LEADERSHIP DEVELOPMENT ARE SOME PROGRAMS. RECRUITMENT OF PHYSICIANS TO THIS RURAL COMMUNITY AND PROVIDING PROGRAMS TO DRIVE ENTRY INTO HEALTH CAREERS AND NURSING PRACTICE ARE TWO OTHER ACTIVITIES. PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 MN X 1 1 X X X X 0 0 0 0 0 0 0 0 0 DR COLIN FENNELL 611754 0 0 0 0 0 13750 0 20314 0 645818 0 0 0 ROSS MATLACK 241213 0 0 0 0 0 13583 0 17084 0 271880 0 0 0 CARRIE MICHALSKI 130046 0 0 0 0 0 7608 0 16359 0 154013 0 0 0 BILL BENNETT 143461 0 0 0 0 0 8057 0 3876 0 155394 0 0 0 DR IDATONYA AFONYA 334826 0 0 0 0 0 13750 0 18130 0 366706 0 0 0 DR OLATUBOSUN FASHORO 455614 0 0 0 0 0 13750 0 18353 0 487717 0 0 0 DR MIRZA BAIG 314432 0 0 0 0 0 13750 0 18090 0 346272 0 0 0 DR ERIK KANTEN 490839 0 0 0 0 0 13750 0 17423 0 522012 0 0 0 DR STEVEN SCHULTZ 327706 0 0 0 0 0 13750 0 15897 0 357353 0 0 0 DR KARI WESSMAN 333873 0 0 0 0 0 0 0 13335 0 347208 0 0 0 A CITY OF CROOKSTON 416005076 227235AL2 2007-05-22 15875000 REFUNDING & CONSTRUCTION 0 0 0 A 1935000 15875000 1161441 317500 14376695 2005 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 RIVERVIEW HAS MEMBERS THAT ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A RIVERVIEW HAS MEMBERS THAT ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM. THE 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND THE ACCOUNTING MANAGER FOR ACCURACY AND COMPLETENESS PRIOR TO FILING. ALL QUESTIONS AND CHANGES ARE ADDRESSED AS NECESSARY. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST SERVES TO PROTECT THE INTEGRITY OF ASSOCIATION INFORMATION, PRODUCTS, SERVICES AND EMPLOYEE EFFORTS. EMPLOYEES ARE EXPECTED TO DEVOTE THEIR BEST EFFORTS AND BE LOYAL TO THE INTERESTS OF RIVERVIEW HEALTH. RIVERVIEW RECOGNIZES THE RIGHT OF EMPLOYEES TO ENGAGE IN ACTIVITIES OUTSIDE OF THEIR EMPLOYMENT HERE, WHICH ARE OF A PRIVATE NATURE AND UNRELATED TO OUR BUSINESS. HOWEVER, A POLICY OF FULL DISCLOSURE WILL BE FOLLOWED TO ASSESS AND PREVENT POTENTIAL CONFLICTS OF INTEREST FROM ARISING. 1. EMPLOYEES WILL NOT BE PERMITTED TO ENGAGE IN ACTIVITIES, WHICH ARE IN COMPETITION WITH THE BUSINESS ACTIVITIES OF RIVERVIEW HEALTH. (EXAMPLES MAY INCLUDE, BUT NOT LIMITED TO, REHAB SERVICES, CD COUNSELING, HOME CARE, OUTSIDE CONSULTATION SERVICES SUCH AS PHARMACY OR DIETETICS, OR OTHER REVENUE PRODUCING AREAS.) 2. EMPLOYEES MUST DISCLOSE IN FULL, AT TIME OF EMPLOYMENT AND ANNUALLY THEREAFTER, ANY ACTIVITY WHICH THEY ENGAGE IN WHICH IS SIMILAR IN NATURE OR IN DIRECT COMPETITION WITH A SERVICE OF RIVERVIEW HEALTH. 3. NO EMPLOYEE MAY ENGAGE IN OUTSIDE WORK THAT WILL INTERFERE WITH HIS OR HER PRIMARY JOB WITH RIVERVIEW HEALTH. THERE IS AN EXPECTATION OF A DUTY OF LOYALTY BY ALL EMPLOYEES. 4. NO EMPLOYEE MAY ACCEPT PAYMENT, RETAINER, COMMISSION, CONSULTING FEE OR ENTER INTO ANY OTHER FEE ARRANGEMENT OR REMUNERATION FOR SERVICES PROVIDED IN CONJUNCTION WITH RIVERVIEW HEALTH OTHER THAN THEIR NORMAL WAGES WITHOUT THE EXPRESS APPROVAL OF ADMINISTRATION. 5. NO OUTSIDE WORK MAY BE DONE DURING AN EMPLOYEE'S WORK HOURS. ASSOCIATION FACILITIES, EQUIPMENT, LABOR OR SUPPLIES MAY NOT BE USED TO CONDUCT NON-RIVERVIEW BUSINESS WITHOUT THE EXPRESS APPROVAL OF ADMINISTRATION. 6. EMPLOYEES MUST DISCLOSE ANY MATERIAL FINANCIAL OR OTHER BENEFICIAL INTEREST IN ANY ENTITY ENGAGED IN THE DELIVERY OF HEALTH CARE SERVICES. 7. EMPLOYEES MUST DISCLOSE ANY MATERIAL FINANCIAL OR OTHER BENEFICIAL INTEREST IN ANY ENTITY ENGAGED IN THE DELIVERY OF GOODS OR SERVICES TO RIVERVIEW HEALTH. 8. FAILURE TO DISCLOSE INFORMATION RELATED TO ANY OF THE ABOVE POINTS TO ADMINISTRATION MAY LEAD TO CORRECTIVE ACTION UP TO AND INCLUDING DISCHARGE. CONFLICT OF INTEREST POLICY IS REVIEWED AND SIGNED OFF ANNUALLY BY ALL EMPLOYEES AND MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 THE RIVERVIEW HEALTHCARE ASSOCIATION BOARD OF DIRECTORS DETERMINE THE COMPENSATION FOR THE CEO. MANAGEMENT POSITIONS COMPENSATION IS DETERMINED BY ADMINISTRATION OFFICERS, REVIEWED BY HUMAN RESOURCES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS FINANCIAL STATEMENTS ARE SUMMARIZED AND MADE AVAILABLE TO THE PUBLIC AT THE ANNUAL MEETING. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A DR. COLIN FENNELL: RIVERVIEW HEALTHCARE ASSOCIATION TIME ALLOCATION: EMPLOYMENT AS A DOCTOR: 40 HOURS PER WEEK BOARD OF DIRECTORS: 1 HOURS PER WEEK RIVERVIEW HEALTHCARE ASSOCIATION COMPENSATION: DOCTOR REPORTABLE COMPENSATION: $ 611,754 DOCTOR OTHER COMPENSATION: $ 34,064 BOARD REPORTABLE COMPENSATION: $ 0 BOARD OTHER COMPENSATION: $ 0 RIVERVIEW HEALTHCARE FOUNDATION 323 SOUTH MINNESOTA ST CROOKSTON MN 56716 411699589 FUNDRAISING MN 501(C)(3) LINE 11A, I 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0