2012-11-15T09:08:19-06:00 2011-12-31 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST STE 2300 MINNEAPOLIS MN 55402 990 2011-01-01 208316475 MAPLE GROVE HOSPITAL CORPORATION MAPL 7635811000 9825 HOSPITAL DRIVE MAPLE GROVE MN 55369 PATRICK BORAN 7635205048 2012-10-30 1 LAWRENCE H MOHR CPA P00447603 6128764500 2011 2016-02-24 21:20:13Z PATRICK BORAN 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 83624454 0 X WWW.MAPLEGROVEHOSPITAL.ORG X 2007 MN GENERAL ACUTE CARE HOSPITAL PROVIDING EMERGENCY SERVICES, MEDICAL AND SURGICAL SERVICES, OBSTETRICAL SERVICES, AND PEDIATRIC SERVICES. 7 2 726 149 0 0 16772 42089 54111374 83565625 537182 16740 0 0 54665328 83624454 0 0 0 0 22124547 32980257 0 0 0 40783745 46807430 62908292 79787687 -8242964 3836767 156370880 174479837 155725125 152776815 645755 21703022 GENERAL ACUTE CARE HOSPITAL PROVIDING EMERGENCY SERVICES, MEDICAL/SURGICAL SERVICES, OBSTETRICAL AND PEDIATRIC SERVICES. 0 0 66903680 83565625 MAPLE GROVE HOSPITAL CORPORATION IS A GENERAL ACUTE CARE HOSPITAL PROVIDING EMERGENCY SERVICES, MEDICAL/SURGICAL SERVICES, OBSTETRICAL AND PEDIATRIC SERVICES. 66903680 1 1 0 0 0 0 0 0 0 0 1 1 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 0 1 89 0 1 726 1 0 0 0 0 0 0 0 0 0 0 X 7 2 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X PATRICK BORAN 7635205048 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 LOREN TAYLOR 2.00 X 0 807651 22052 VIRGINIA MALONE 2.00 X 0 260962 7591 KEVIN CROSTON MD 2.00 X 0 582065 16652 PATRICK BORAN 2.00 X 0 464704 38809 MARK EUSTIS 2.00 X 0 0 0 DAN FROMM 2.00 X 0 0 0 TIFFANY ZITZEWITZ 2.00 X 0 123090 6820 ANDREW COCHRANE 50.00 X X 0 382446 19967 LETTY TAM 40.00 X 118061 0 4217 KAREN HALL 40.00 X 125174 0 10849 VINCENT ADANENE 40.00 X 124968 0 6914 THOMAS HOLETS 0.00 X 0 63875 0 PAMELA LINDEMOEN 0.00 X 0 498750 707 368203 3183543 134578 22 1 1 0 ARAMARK CORPORATION 25271 NETWORK PLACE CHICAGO IL 60673 DIETARY 968765 GECKO GROUP 1472 IOWA AVE W ST PAUL MN 55108 IT SERVICES 239105 ARAMARK HEALTHCARE FOOD 25271 NETWORK PLACE CHICAGO IL 60673 MANAGEMENT SUPPORT FOR DIETARY 213069 CAREFUSION SOLUTIONS LLC 25082 NETWORK PLACE CHICAGO IL 60673 IT SERVICES 166439 MEDICAL STAFFING NETWORK PO BOX 202996 DALLAS TX 75320 CONSULTING 129812 7 42089 42089 PATIENT REVENUE 621500 82356347 82356347 CONTRACT SERVICES 900099 522483 522483 CAFETERIA 900099 379320 379320 GIFT SHOP 900099 179290 179290 MISCELLANEOUS 900099 93770 93770 34415 34415 83565625 42 42 16698 16698 83624454 83565625 0 16740 27919476 22665031 5254445 404484 328360 76124 2683912 2178800 505112 1972385 1601182 371203 46662 37880 8782 28400 23055 5345 13603507 11043327 2560180 66318 53837 12481 1659064 1346828 312236 7210098 7210098 7779950 6315763 1464187 625437 507730 117707 SUPPLIES 10121290 8216463 1904827 BAD DEBT EXP 2635709 2635709 GOVERNMENT TAXES 1482758 1482758 MAINTENANCE & REPAIRS 918919 745978 172941 629318 510881 118437 79787687 66903680 12884007 0 5800194 3551 19246645 8569814 15015249 1291536 1442460 156420 473511 136943105 15134396 120353473 121808709 17693689 12926288 0 3607000 2505754 -43576 156370880 174479837 3589248 11349806 148218570 141427009 3917307 0 155725125 152776815 X 645755 21703022 645755 21703022 156370880 174479837 X 3836767 17220500 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 103785115 6901359 96883756 33157990 8233037 24924953 121808709 CASH ON DEPOSIT WITH BOND TRUSTEE 12926288 F 12926288 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MAPLE GROVE EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS, AND THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2011 OR 2010. MAPLE GROVE IS NOT CURRENTLY UNDER EXAMINATION BY ANY TAXING JURISDICTION. 1 1 1 X 1 X 1 1 1 0 1 1 3062243 3062243 0.03840 9386850 7101667 2285183 0.02860 12449093 7101667 5347426 0.06700 4693470 4706718 -13248 0.00000 4693470 4706718 -13248 17142563 11808385 5334178 0.06700 1 948855 11318261 14185114 -2866853 X 1 1 1 1 MAPLE GROVE HOSPITAL CORPORATION

9825 HOSPITAL DRIVE MAPLE GROVE MN 55369

X X X MAPLE GROVE HOSPITAL CORPORATION 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 1 PART III, LINE 4: MAPLE GROVE HOSPITAL'S AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE DESCRIPTION ABOUT BAD DEBT EXPENSE. THE COST TO CHARGE RATIO WAS USED TO DETERMINE THE AMOUNT ON PART III, SECTION A, LINE 2. WE DO NOT HAVE THE INFORMATION NECESSARY TO DETERMINE WHICH PORTION OF THE AMOUNT REPORTED ON LINE 2 IS COMMUNITY BENEFIT. PART III, LINE 8: THE SHORTFALL REPORTED REPRESENTS THE AMOUNT MEDICARE REIMBURSEMENT IS LESS THAN THE ESTIMATED COST OF PROVIDING SERVICES TO THOSE PATIENTS. THE METHOD USED TO ESTIMATE THOSE COSTS IS THE COST TO CHARGE RATIO APPROACH WHICH CALCULATES THE RATIO OF TOTAL HOSPITAL COSTS / TOTAL HOSPITAL GROSS REVENUE AND THEM APPLIES THAT RATIO TO TOTAL MEDICARE GROSS REVENUE. PART III, LINE 9B: MAPLE GROVE HOSPITAL CORPORATION HAS POLICIES AND PROCEDURES IN PLACE FOR COLLECTION PRACTICES THAT INCLUDE IDENTIFICATION AND SCREENING FOR CHARITY CARE AND FINANCIAL ASSISTANCE. THE POLICIES ARE AVAILABLE ON THE ORGANIZATIONS INTRANET AND EACH PATIENT IS GIVEN A BROCHURE UPON ADMISSION. MAPLE GROVE HOSPITAL CORPORATION PART V, SECTION B, LINE 19D: THE MINNESOTA ATTORNEY GENERAL'S OFFICE REQUIRES HOSPITALS TO RENDER SERVICES TO THOSE PATIENTS WHO DO NOT HAVE INSURANCE AT A REDUCED RATE EQUAL TO THE DISCOUNT INCURRED FROM THE HIGHEST VOLUME MANAGE CARE PLAN. MAPLE GROVE HOSPITAL CORPORATION PART V, SECTION B, LINE 21: ALL SERVICES ARE CHARGED TO ALL PATIENTS AT THE SAME PROCESS PER PROCEDURE REGARDLESS OF INSURANCE STATUS. PAYMENTS FOR THOSE SERVICES WILL VARY DEPENDING ON EXISTING INSURANCE ARRANGEMENTS, ELIGIBILITY FOR CHARITY AND UNINSURED DISCOUNTS. PART VI, LINE 2: MAPLE GROVE HOSPITAL CORPORATION MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF COMMUNITY BENEFITS AND CHARITY CARE IT PROVIDES. THOSE RECORDS INCLUDE MANAGEMENT'S ESTIMATE OF THE COST TO PROVIDE CHARITY CARE, THE COST OF THE SERVICES AND SUPPLIES FURNISHED FOR COMMUNITY BENEFIT PROGRAMS AND PUBLIC PROGRAM PAYMENT DEFICITS. PART VI, LINE 3: MAPLE GROVE HOSPITAL HAS A PROACTIVE PROGRAM TO ASSIST UNINSURED AND UNDERINSURED PATIENTS WITH THEIR MEDICAL BILLS. WE COMPLY WITH THE ATTORNEY GENERAL'S REQUIREMENT TO PROVIDE AN IMMEDIATE DISCOUNT TO UNINSURED MINNESOTA RESIDENTS. WE HAVE PATIENT FINANCIAL ADVOCATES AS WELL AS A CONTRACTED VENDOR THAT MEETS WITH ALL OF OUR UNINSURED INPATIENTS AND SPECIFIC OUTPATIENTS TO ASSIST THEM IN MEDICAL ASSISTANCE ELIGIBILITY AND APPLICATIONS. THIS COULD INCLUDE A VISIT TO THEIR RESIDENCE IF THEY NEED HELP IN COMPLETING ASSISTANCE APPLICATIONS. SHOULD THEY NOT QUALIFY FOR STATE OR FEDERAL ASSISTANCE PROGRAMS, WE OFFER AND ASSIST THEM IN APPLYING FOR THE HOSPITAL'S FINANCIAL ASSISTANCE (CHARITY CARE) PROGRAM.OUR CHARITY CARE PROGRAM IS PUBLISHED IN THE CORPORATE POLICIES AND PROCEDURES AND PROVIDES FOR 100% COVERAGE OF MEDICAL BILLS FOR ANYONE WHOSE INCOME IS LESS THAN 200% OF THE FEDERAL POVERTY GUIDELINES AND NEEDS ASSISTANCE IN RESOLVING THEIR FINANCIAL OBLIGATION TO THE HOSPITAL. THERE IS A GRADUAL REDUCTION IN THE CHARITY COVERAGE BETWEEN THE 201% AND 400% OF THE FEDERAL POVERTY GUIDELINES.IF WE ARE UNABLE TO MEET WITH THE PATIENT BEFORE DISCHARGE FROM MAPLE GROVE HOSPITAL, THE PATIENT IS GIVEN A PAMPHLET THAT LISTS CONTACT NUMBERS TO OUR BUSINESS OFFICE CUSTOMER SERVICE AREA TO DISCUSS OPTIONS FOR ASSISTANCE WITH THEIR MEDICAL BILLS. THIS CONTACT INFORMATION IS ALSO PROVIDED ON EVERY STATEMENT THAT IS SENT TO OUR CUSTOMERS. IN ADDITION, OUR INTERNAL COLLECTIONS DEPARTMENT AND OUR COLLECTION AGENCIES ARE WELL VERSED IN OUR ASSISTANCE PROGRAMS AND WILL ASSESS DURING THEIR CONVERSATIONS WITH PATIENTS IF REFERRAL TO EITHER A STATE OR FEDERAL PROGRAM OR OUR CHARITY CARE PROGRAM WOULD BE APPROPRIATE. 1 X X X X 1 0 0 0 0 0 0 0 0 LOREN TAYLOR 0 606008 0 0 0 201643 0 7653 0 14399 0 829703 0 0 VIRGINIA MALONE 0 260962 0 0 0 0 0 1246 0 6345 0 268553 0 0 KEVIN CROSTON MD 0 401954 0 0 0 180111 0 8063 0 8589 0 598717 0 0 PATRICK BORAN 0 341414 0 0 0 123290 0 30800 0 8009 0 503513 0 63278 ANDREW COCHRANE 0 331154 0 0 0 51292 0 10402 0 9565 0 402413 0 0 THOMAS HOLETS 0 63875 0 0 0 0 0 0 0 0 0 63875 0 63875 PAMELA LINDEMOEN 0 0 0 0 0 498750 0 0 0 707 0 499457 0 61250 CITY OF MAPLE GROVE 208316475 770278AA7 2007-05-01 149139758 CONSTRUCTION OF A HOSPITAL FACILITY 0 1 0 149139758 2686779 4768248 12923728 2009 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 12: EXPLANATION OF UNSPENT FUNDS: UNSPENT FUNDS ARE DUE TO A HIGHLY COMPETITIVE BIDDING ENVIRONMENT DURING THE PROJECT, I.E. BETTER PRICING AND VALUE ENGINEERING THAN EXPECTED. THE EXCESS WILL BE USED TO COMPLETE THE 4TH FLOOR AT AN ESTIMATED COST OF $20 MILLION. FORM 990, PART VI, SECTION A, LINE 3 NORTH MEMORIAL HEALTH CARE, A RELATED PARTY, PERFORMS MANAGEMENT DUTIES ON BEHALF OF MAPLE GROVE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 6 MAPLE GROVE HOSPITAL HAS ONE CLASS OF MEMBERS. NORTH MEMORIAL HEALTH CARE ("NORTH MEMORIAL") AND FAIRVIEW HEALTH SERVICES ("FAIRVIEW") ARE THE ONLY MEMBERS OF THE CORPORATION AND BOTH MEMBERS ARE NONPROFIT, TAX-EXEMPT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS IS COMPRISED OF SEVEN VOTING DIRECTORS AND ONE NON-VOTING DIRECTOR, AS FOLLOWS: (A) THE CHIEF EXECUTIVE OFFICER OF NORTH MEMORIAL AND FOUR OTHER DIRECTORS APPOINTED ANNUALLY BY NORTH MEMORIAL (B) THE CHIEF EXECUTIVE OFFICER OF FAIRVIEW AND ONE OTHER DIRECTOR APPOINTED ANNUALLY BY FAIRVIEW AND (C) THE MAPLE GROVE HOSPITAL CHIEF EXECUTIVE OFFICER. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS, AND ONLY THE MEMBERS, MAY TAKE DIRECT ACTION ON THE FOLLLOWING MATTERS BY UNANIMOUS MEMBER APPROVAL: (A) AMENDMENTS TO THE ARTICLES OF INCORPORATION; (B) AMENDMENTS TO THE BYLAWS; (C) MERGER OR CONSOLIDATION OF THE CORPORATION (D) SALE, LEASE OR TRANSFER OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; (E) JOINT VENTURES AFFECTING SUBSTANTIALLY ALL OF THE ASSETS OR OPERATIONS OF THE CORPORATION; (F) DETERMINATION OF THE NAME UNDER WHICH THE HOSPITAL CONDUCTS BUSINESS; (G) CERTAIN MORTGAGES OR OTHER SECURITY INTERESTS; (H) ISSUANCE OF CAPITAL CALLS; AND (I) DISSOLUTION AND LIQUIDATION OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE MANAGEMENT COMPANY AND THE BOARD OF DIRECTORS REVIEW THE FORM 990 BEFORE IT IS FILED. REPRESENTATIVES FROM THE HOSPITAL'S INDEPENDENT ACCOUNTING FIRM REVIEW THE FORM 990 WITH THE MANAGEMENT COMPANY IN DETAIL AND NOTES FOR THE COMMITTEE ANY CHANGES IN THE FORM 990 FROM PRIOR YEARS. AFTER THOROUGH DISCUSSION, THE MANAGEMENT COMPANY APPROVES THE FORM 990 AND FORWARDS IT TO THE BOARD FOR ITS REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL MEMBERS OF THE BOARD OF DIRECTORS AND ALL EMPLOYEES RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY EACH YEAR. EACH BOARD MEMBER AND STAFF MEMBER FILLS OUT A CONFLICT OF INTEREST QUESTIONNAIRE IN WHICH THEY ARE ASKED TO IDENTIFY ANY RELATIONSHIP THAT WOULD CREATE A CONFLICT OF INTEREST. THE RESULTS ARE SUMMARIZED AND REVIEWED TO DETERMINE ANY ACTUAL OR POTENTIAL CONFLICT AND ARE REPORTED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR KEY POSITIONS ARE REVIEWED BY THE EXECUTIVE COMMITTEE OF NORTH MEMORIAL WORKING IN CONJUNCTION WITH AN OUTSIDE CONSULTANT. THE EXECUTIVE COMMITTEE OF NORTH MEMORIAL INSURES THAT THE SALARY AND BENEFIT ADMINISTRATION REVIEW PROCESS IS BEING FOLLOWED, WHICH INCLUDES SALARY AND BENEFIT SURVEYS AND COMPARISONS OF ALL POSITIONS. THE CEO'S COMPENSATION IS SENT TO THE FULL BOARD FOR APPROVAL. THE COMPENSATION OF ALL OTHER KEY POSITIONS IS APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE SECRETARY OF THE STATE FILING WITH THE STATE OF MINNESOTA. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CONTRIBUTED CAPITAL FROM SHAREHOLDERS 3,750,000. GAIN ON CONSOLIDATION 13,470,500. TOTAL TO FORM 990, PART XI, LINE 5: 17,220,500. FORM 990, PART IX, LINCE 2C: THE ORGANIZATION DID NOT CHANGE EITHER THE OVERSIGHT PROCESS OF THE AUDIT OR THE SELCTION PROCESS OF THE INDEPENDENT ACCOUNTANT IN THE CURRENT YEAR. NORTH MEMORIAL HEALTH CARE 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 410729979 ACUTE CARE MN 501(C)(3) LINE 3 NORTH MEMORIAL 0 NORTH MEMORIAL COMMUNITY FOUNDATION 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 411777966 FUNDRAISING MN 501(C)(3) 7 NORTH MEMORIAL 0 ASSOCIATED HEALTH ASSURANCE 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 980343815 INSURANCE BD 501(C)(3) 11A NORTH MEMORIAL 0 NORTH MEMORIAL SURGERY CENTER AT MAPLE GROVE 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 OUTPATIENT SURGERY MN N/A NORTH MEMORIAL ENDOSCOPY CENTER AT MAPLE GROVE 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 OUTPATIENT SURGERY MN N/A MONTICELLO CANCER CENTER 1013 HARAT BLVD MONTICELLO MN 55362 CANCER CENTER MN N/A MINNESOTA DIAGNOSTIC IMAGING PARTNERS LLC 9855 HOSPITAL DRIVE MAPLE GROVE MN 55422 RADIOLOGY MN N/A OAKDALE HEALTH ENTERPRISES INC 3300 OAKDALE AVENUE NORTH ROBBINSDALE MN 55422 411546422 AMBULANCE MN N/A C 0 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 NORTH MEMORIAL HEALTH CARE C 2812500 CASH NORTH MEMORIAL HEALTH CARE E 107703750 AMOUNT GUARANTEE NORTH MEMORIAL HEALTH CARE J 564633 AMOUNT PAID NORTH MEMORIAL HEALTH CARE O 5481484 AMOUNT PAID NORTH MEMORIAL HEALTH CARE L 4823684 AMOUNT PAID