2013-11-08T10:49:27-06:00 2012-12-31 861065772 DELOITTE TAX LLP 50 SOUTH SIXTH STREET STE 2800 MINNEAPOLIS MN 55402 990 2012-01-01 411756478 Children's Health Care Services Inc DBA Children's - Minnetonka CHIL 6128136000 2525 Chicago Avenue South Minneapolis MN 554040000 ALEC MAHMOOD 6128136000 2013-10-30 1 Kristina Rasmussen P00143920 6123974000 2012 2016-03-07 17:11:31Z Children's - Minnetonka Alec Mahmood 2525 Chicago Avenue South Minneapolis MN 554040000 8834063 0 X childrensmn.org X 1994 MN We serve the community's children as a superior, pediatric specialty health care center. 8 6 60 10 0 0 0 2378 8273515 7780301 0 0 434396 392884 8707911 8175563 0 0 0 0 4117181 4480788 0 0 0 3652725 3179912 7769906 7660700 938005 514863 7062570 7471219 231483 125269 6831087 7345950 X We serve the community's children as a specialty pediatric ambulatory surgery center and diagnostic and treatment facility. 0 0 6492269 7780301 Children's Health Care Services, Inc. ("Children's - Minnetonka") provides state-of-the-art, compassionate pediatric specific outpatient care. Our facilities and services are designed exclusively for the needs of children and their families. Our medical equipment is tailored to fit children, and our staff is trained and experienced to care for the special physical and emotional needs of children. We provide a lower cost environment and option to the community we serve than what can generally be provided in a hospital setting. Children's - Minnetonka performed 3,627 outpatient surgical cases, and 5,206 radiology and special diagnostic tests. See Schedule O.We perform general and specialty surgical procedures, including dental/oral, gastroenterology, orthopaedic, ophthalmology, plastics, urology, physiatry (botox/phenol injections), ear, nose, and throat. Surgery is performed by a team of professionals who specialize in the unique needs of children. Among them is the pediatric anesthesia team, who work solely with children and understand their specific medical needs. At Children's - Minnetonka, we provide the following radiology and special diagnostic services: magnetic resonance imaging (MRI) and computerized tomography (CT) scans, ultrasound, auditory brain stem envoked responses, and general radiology and fluoroscopic procedures including diagnostic X-rays, upper gastrointestinal images, and colon exams. Nitrous sedation and anesthesia services are available. The nitrous oxide sedation program at Children's - Minnetonka is a breakthrough, award-winning program. Patients are awake but calm during its administration before and during the procedure. Nitrous oxide frees patients from the side effects typically associated with other sedatives. While other sedatives may stay in a child's system for hours, nitrous oxide quickly leaves children's systems, enabling them to resume normal activities such as school. 6492269 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 60 1 0 0 0 0 0 0 0 0 0 0 0 X 8 6 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X Alec Mahmood 6128136113 2525 Chicago Avenue South Minneapolis MN 55404 Phil Kibort MD 1.50 50.00 X X 0 674587 52212 Jerry Massmann 1.50 52.00 X X 0 646564 50702 Brian Larson 1.00 X 0 0 0 David Dorn 1.00 X 0 0 0 Eric Simso 1.00 X 0 0 0 Janet Swiecichowski 1.00 X 0 0 0 Karen Laurean Walkowski 1.00 X 0 0 0 Lorene Freehil MD FAAP 1.00 X 0 0 0 Gloria Drake 6.00 50.00 X 28457 177844 46003 Julianne Wagner 50.00 X 123001 0 11669 Barbara Kleven 40.00 X 114521 0 4605 Janice Anderson 40.00 X 161240 0 21011 Judy Holasek-Fritz 40.00 X 155610 0 23390 Mary Lovejoy 40.00 X 150195 0 23473 733024 1498995 233065 5 0 1 0 Metro Anesthesia Network Suite 20 14700 28th Avenue North Plymouth MN 55441 Anesthesia 384912 GE Healthcare PO Box 96483 Chicago IL 60693 MRI Service Agreement 105745 2 2378 2378 Patient Service 621400 6646075 6646075 Medicare / Medicaid Pa 621400 1129679 1129679 Commission Machines Re 722210 2303 2303 2244 2244 7780301 1051384 658500 392884 392884 392884 8175563 7777998 0 395187 X 34800 34800 3502921 3157485 345436 222845 190575 32270 511955 440368 71587 208267 182284 25983 44800 44800 982654 808324 174330 73008 48071 24937 110916 102036 8880 119412 119412 7704 6669 1035 7564 6814 750 59781 59781 829410 431571 397839 4572 4572 Medical Supplies 744267 744267 MN Care Tax 146660 146660 Bad Debt 43380 43380 5784 5784 7660700 6492269 1168431 0 796908 795676 80333 1258269 22581229 17163955 6185329 5417274 7062570 7471219 141578 93115 89905 32154 231483 125269 X 6831087 7345950 6831087 7345950 7062570 7471219 514863 0 X 0 1 X 1 0 X 675764 675764 14795577 10933649 3861928 0 7109888 6230306 879582 0 5417274 MN CARE TAX RESERVE 32154 32154 X 8785145 609582 609582 8175563 0 8175563 8270282 609582 609582 7660700 0 7660700 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Internal Revenue Service (IRS) has determined that Children's and its subsidiaries are exempt organizations as described in Section 501(c)(3) of the Internal Revenue Code (IRC). Children's believes that it continues to meet the requirements of the IRC to sustain its tax-exempt status. There are no federal income tax expenses, penalties, or interest recognized in the consolidated statements of operations and no unrecognized tax benefits for the years ended December 31, 2012 and 2011. Part XI, Line 2d - Other Adjustments: Rental Expenses Included in Income 609,582. Part XII, Line 2d - Other Adjustments: Rental Expenses Included in Income 609,582. 0 1 0 0 0 0 0 0 0 Phil Kibort MD 0 454271 0 203112 0 17204 0 30600 0 21612 0 726799 0 0 Jerry Massmann 0 431668 0 191985 0 22911 0 34180 0 16522 0 697266 0 0 Gloria Drake 24666 154195 3791 23649 0 0 4111 25704 2232 13956 34800 217504 0 0 Janice Anderson 156564 0 4676 0 0 0 4915 0 16096 0 182251 0 0 0 Judy Holasek-Fritz 151068 0 4542 0 0 0 4092 0 19298 0 179000 0 0 0 Mary Lovejoy 145519 0 4676 0 0 0 4640 0 18833 0 173668 0 0 0 Part I, Line 4b Certain employees of Children's Health Care,Inc., parent of Children's - Minnetonka, are provided the opportunity to participate in the Capital Accumulation Plan ("the Capital Plan"). The Capital Plan requires that the employee is a physician or executive and is a .5 FTE or more in order to be eligible to participate in the Capital Plan. Payments from the Capital Plan occur at vesting and are based on percentage of salary. The following amounts represent the amount paid under the Capital Plan in 2012. Phil Kibort $65,874 Jerry Massmann $47,826 Certain employees of Children's Health Care, Inc., parent of Children's - Minnetonka, are provided the opportunity to participate in the Deferral Account Pay Plan ("the Deferral Plan"). The Deferral Plan requires that the employee is a physician or executive and is a .5 FTE or more in order to be eligible to participate in the Deferral Plan. Payments from the Deferral Plan occur at vesting and are based on percentage of salary. There were no amounts paid under the Deferral Plan in 2012. Supplemental Information Part III Part I, Line 3: Children's - Minnetonka relies on Children's Health Care, Inc., the parent of Children's - Minnetonka, to establish the compensation of the organization's CEO. Children's Health Care, Inc. uses the following methods to establish compensation of the CEO: compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board or compensation committee. Form 990, Part VI, Section A, line 2 The following people have a business relationship: Phil Kibort, Jerry Massmann, Gloria Drake. Form 990, Part VI, Section A, line 6 Children's - Minnetonka has a sole member, Children's Health Care, Inc., a Minnesota nonprofit corporation. Form 990, Part VI, Section A, line 7a Children's - Minnetonka's sole member, Children's Health Care, Inc., is authorized under Children's - Minnetonka's bylaws to elect directors of Children's - Minnetonka, after approval by the board of directors of Children's - Minnetonka. Form 990, Part VI, Section A, line 7b Children's - Minnetonka's sole member, Children's Health Care, Inc., maintains a number of "reserved powers" including but not limited to election of directors, approval of annual budgets, approval of amendments to the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11 The senior management of Children's Health Care, Inc., the parent of Children's - Minnetonka, reviews the draft of Form 990 with the Audit and Compliance Committee of Children's Health Care's governing body prior to the filing of the form. This review includes an overview of the form and discussion related to key sections. Copies of the final Form 990 are made available to members of the committee and all directors prior to the Form being filed. The Audit and Compliance Committee has been delegated the authority to oversee the completion and filing of the Form 990 by the full Children's Health Care Board, and the Committee reports the results of its review and approval to the full board at a regularly scheduled board meeting. Form 990, Part VI, Section B, line 12c Management of Children's Health Care, Inc., the parent of Children's - Minnetonka, ensure that conflict of interest disclosure forms are completed by all members of the governing body and board committees at least annually. Forms are completed at the beginning of the year, and directors and committee members are instructed to provide additional disclosures if necessary during the course of the year. The Governance Committee of the governing body of Children's Health Care, along with senior management (CEO and general counsel) of Children's Health Care, Inc., review all disclosures provided by governing board members. The results of this review and any concerns, limitations, etc. are reported by the Governance Committee to the full board. If conflicts are identified, the Governance Committee and management work to ensure that directors do not participate in discussion or voting on the affected matter. Form 990, Part VI, Section B, line 15 The compensation for the President of Children's - Minnetonka is established by Children's Health Care, Inc. as part of its executive compensation process. Children's Health Care, Inc. follows the requirements set forth in the IRS rebuttable presumption of reasonableness is determining compensation for the President and other officers and executive leaders of Children's - Minnetonka. This function is performed by the Compensation Committee of the governing board of Children's Health Care, Inc., which is composed of only independent directors. The process includes review of comparability data, retention of an outside compensation consultant and contemporaneous substantiation of the deliberation and decision through detailed minutes of the Compensation Committee and full board meetings where executive compensation is considered. Form 990, Part VI, Section C, line 19 Children's Health Care, Inc., the parent of Children's - Minnetonka, makes financial statement information public through a summary of financial performance in its annual report. In addition, financial statements are provided to Children's Health Care's bond trustees, who thereafter make this information publicly available. Children's - Minnetonka relies on the Conflict of Interest Policy of Children's Health Care, the parent of Children's - Minnetonka, Children's Health Care, Inc. does not make the Conflict of Interest Policy available to the public. The governing documents of Children's - Minnetonka are not available to the public. Other Fees Form 990, Part IX, line 11g Medical Director Contracts: Program service expenses 20,000. Management and general expenses 0. Fundraising expenses 0. Total expenses 20,000. Purchased Services: Program service expenses 627,100. Management and general expenses 86,364. Fundraising expenses 0. Total expenses 713,464. Equipment lease, repair and service: Program service expenses 161,224. Management and general expenses 87,966. Fundraising expenses 0. Total expenses 249,190. Children's Health Care Inc 2525 Chicago Avenue South Minneapolis MN 554041844 411754276 Healthcare MN 501(c)(3) Line 3: 170(b)(1)(a) N/A 0 Children's Health Care Foundation 2525 Chicago Avenue South Minneapolis MN 554021844 411814223 Healthcare MN 501(c)(3) Line 7: 170(b)(1)(a) N/A 1 Children's Clinic Network 2525 Chicago Avenue South Minneapolis MN 554041844 453765330 Healthcare MN 501(c)(3) Line 7: 170(b)(1)(a) N/A 1 Mother Baby Facility LLC 2525 Chicago Avenue South Minneapolis MN 554041844 454078371 Healthcare MN 501(c)(3) Line 11: 509(a)(3) N/A 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 1 0 0 0