2011-11-01T08:03:02-05:00 2010-12-31 BRADY MARTZ AND ASSOCIATES PC PO BOX 14296 GRAND FORKS ND 582084296 990 2010-01-01 450310462 ALTRU HEALTH SYSTEM ALTR 7017805200 1200 S COLUMBIA RD GRAND FORKS ND 582014036 DAVID MOLMEN 7017805200 2011-10-24 1 PETER HOISTAD 7017754685 2010 2016-03-07 17:11:31Z ALTRU HOSPITAL DAVID MOLMEN 1200 S COLUMBIA RD GRAND FORKS ND 582014036 423018365 0 X ALTRU.ORG X 1970 ND HEALTHCARE DELIVERY 11 6 4108 344 2338689 0 1992352 1769870 387027222 398290568 3294228 3874572 438722 441490 392752524 404376500 62962 68673 0 0 226898441 235908618 0 0 0 148676153 145094004 375637556 381071295 17114968 23305205 305326675 371999674 190056742 227020666 115269933 144979008 X IMPROVING HEALTH, ENRICHING LIFE.WHY WE SERVE: TO ACHIEVE OPTIMUM HEALTH FOR ALL RESIDENTS IN OUR REGION.HOW WE SERVE: BY PROVIDING HEALTH EDUCATION, PREVENTIVE SERVICES, EARLY INTERVENTION, AND APPROPRIATE CARE.WHOM WE SERVE: THE MORE THAN 200,000 RESIDENTS OF NORTHEAST NORTH DAKOTA AND NORTHWEST MINNESOTA.WHO WE ARE: A COMMUNITY OF OVER 3,000 HEALTH PROFESSIONALS AND SUPPORT STAFF COMMITTED TO SERVING THE REGION FOR MORE THAN 100 YEARS. 0 0 17555778 21812238 ORTHOPEDICS - ALTRU'S TEAM OF ORTHOPEDIC SURGEONS PROVIDE INPATIENT AND OUTPATIENT SURGICAL SERVICES TO PATIENTS WITH ISSUES RANGING FROM SIMPLE FRACTURES TO COMPLEX TRAUMATIC INJURIES. IN 2010 THERE WERE 1,673 HOSPITAL DISCHARGES. 13608082 18032640 CARDIOLOGY - ALTRU OFFERS COMPREHENSIVE SERVICES INCLUDING INTERVENTIONAL AND MEDICAL CARDIOLOGY. ADDITIONAL SERVICES INCLUDE ECHOCARDIOGRAPHY, CARDIAC STRESS TESTS, AND CARDIAC REHAB. ALTRU HAS BEEN RECOGNIZED THREE TIMES AS A "100 TOP HOSPITALS" FOR CARDIOVASCULAR CARE. OUR CARDIOLOGY TEAM ALSO PROVIDES OUTREACH CLINIC SERVICES TO COMMUNITIES THROUGHOUT OUR SERVICE AREA. IN 2010 THERE WERE 1,717 HOSPITAL DISCHARGES. 9242009 14066914 GENERAL SURGERY - ALTRU'S TEAM OF GENERAL SURGEONS PERFORM INPATIENT AND OUTPATIENT SURGERY FROM ELEVEN OPERATING ROOM SUITES IN ALTRU HOSPITAL. IN 2010 THERE WERE 1,001 GENERAL SURGERY HOSPITAL DISCHARGES. 307524870 340903727 OTHER PROGRAM SERVICES INCLUDE OTHER PATIENT CARE AND GENERAL & ADMINISTRATIVE 307524870 340903727 347930739 1 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 100 0 4108 1 1 1 0 0 0 0 0 0 0 0 0 X 11 6 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DWIGHT THOMPSON 7017805200 1200 SOUTH COLUMBIA ROAD GRAND FORKS ND 58201 KRIS COMPTON 1.00 X 0 0 0 PHILIP GISI 1.00 X 0 0 0 DONALD DEBELTZ MD 40.00 X 457594 0 30990 JAMES HARGREAVES DO 40.00 X 405651 0 26466 ALICE BREKKE 1.00 X 0 0 0 MATTHEW ROLLER MD 1.00 X 401041 0 29341 JUDITH PAUKERT 1.00 X 0 0 0 LONNIE LAFFEN 1.00 X X 0 0 0 JOHN SNUSTAD 1.00 X X 0 0 0 DARRELL LARSON ESQ 1.00 X X 0 0 0 CASEY RYAN MD 40.00 X X 455701 0 26990 DAVID MOLMEN 40.00 X X 390152 0 29990 TIMOTHY P SAYLER 40.00 X X 273701 0 26417 DWIGHT THOMPSON 40.00 X 318258 0 30990 JAMES VANLOOY MD 40.00 X 296085 0 26890 MARGARET REED RN 40.00 X 203297 0 15078 RENEE M AXTMAN RN 40.00 X 189153 0 17962 ROBERT THOMPSON MD MBA 40.00 X 199808 0 0 LELAND LINDQUIST 40.00 X 227093 0 17254 JACQUELYN WALSH 40.00 X 172192 0 11569 DENNIS REISNOUR 40.00 X 180755 0 15898 KENNETH VEIN 40.00 X 174761 0 13776 MARK WAIND 40.00 X 167746 0 12574 BRADLEY WEHE 40.00 X 181351 0 16301 KERRY P CARLSON 40.00 X 162070 0 14002 KELLY HAGEN RN 40.00 X 155204 0 12808 CYNTHIA BRASETH 40.00 X 176422 0 4688 MOHAMED CHEBACLO 40.00 X 1026186 0 24387 MICKEY SYRQUIN 40.00 X 1074367 0 22387 IKECHUKWU ONYEKA 40.00 X 947647 0 26587 RONALD BROCKMAN 40.00 X 876128 0 25187 ABDEL AHMED 40.00 X 1619948 0 27387 10732311 0 505919 221 0 1 0 EPIC SYSTEMS CORPORATION PO BOX 88314 MILWAUKEE WI 532880314 SERVICES 4755388 DELPHI HEALTHCARE PARTNERS INC 170 SOUTHPORT DR MORRISVILLE NC 27560 LOCUM TENENS SERVICES 2272352 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 554809146 SERVICES 1367916 COMPHEALTH MEDICAL STAFFING INC PO BOX 972670 DALLAS TX 753972670 LOCUM TENENS SERVICES 1348364 C & R CLEANERS AND LAUNDRY 1010 N 5TH ST GRAND FORKS ND 58203 SERVICES 948032 39 760845 858038 150987 1769870 NET SERVICE TO PATIENT 621110 389501893 387604694 1897199 PROGRAM SERVICE REVENU 621110 8329396 7043491 1285905 RESEARCH GRANTS 621500 413627 413627 BIOMED SERVICES/SITE S 900099 45652 45652 398290568 4120865 4120865 18395572 18460131 181734 -64559 -181734 -246293 -246293 FITNESS PROGRAM 621990 243686 243686 RENTAL OFFICE SPACE/PA 621300 185940 185940 TELECOMMUNICATIONS 517000 6201 6201 5663 5663 441490 404376500 394815519 2338689 5452422 65073 65073 3600 3600 5595773 1702535 3893238 189696609 175403920 14292689 12888359 11917286 971073 16099838 14886796 1213042 11628039 10583994 1044045 1100882 1100882 2229097 2114619 114478 6514114 6514114 18133868 18133868 SUPPLIES 57780164 57277533 502631 PURCHASED SERVICES 23713177 16869422 6843755 BAD DEBTS 18475082 18475082 FEES 7276262 6472089 804173 OTHER 6289244 2827812 3461432 3582114 3582114 381071295 347930739 33140556 0 11676 28699650 23407475 57058830 67962023 347326 489594 5712762 6492670 399407 325706 329329535 198496205 118771382 130833330 78450120 113283975 15887198 29193225 305326675 371999674 32535546 39489667 286609 347935 142396898 166477752 14837689 20705312 190056742 227020666 X 115269933 144979008 115269933 144979008 305326675 371999674 X 23305205 6403870 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10868382 10868382 155187540 88661618 66525922 5423064 4258599 1164465 156422016 105575988 50846028 1428533 1428533 130833330 ASSETS HELD BY TRUSTEE 2123152 UNAMORTIZED BOND ISSUE COSTS 4035096 INVESTMENTS 3537372 ASSETS HELD UNDER BOND INDENTURE AGREEMENTS 19439743 DUE FROM AFFILIATES 57862 29193225 DUE TO AFFILIATES 23580 POST RETIREMENT HEALTH BENEFIT 11498238 OTHER 5829274 ESTIMATED THIRD PARTY LIABILITY 3354220 20705312 404376500 381071295 23305205 6352734 51136 6403870 29709075 410910968 6352734 6352734 404558234 -181734 -181734 404376500 381297560 226265 226265 381071295 0 381071295 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES THE COMPANY'S POLICY IS TO EVALUATE THE LIKELIHOOD THAT ITS UNCERTAIN TAX POSITIONS WILL PREVAIL UPON EXAMINATION BASED ON THE EXTENT TO WHICH THOSE POSITIONS HAVE SUBSTANTIAL SUPPORT WITHIN THE INTERNAL REVENUE CODE AND REGULATIONS, REVENUE RULINGS, COURT DECISIONS AND OTHER EVIDENCE. IT IS THE OPINION OF MANAGEMENT THAT THE COMPANY HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS THAT WOULD BE SUBJECT TO CHANGE UPON EXAMINATION. PART XI, LINE 8 - OTHER ADJUSTMENTS: APPLICATION OF FASB ASC TOPIC 715 UNREALIZED IMPAIRMENT LOSS PART XII, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF EQUIPMENT PART XIII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF EQUIPMENT IMPAIRMENT LOSS 1 1 X 1 X 1 X 1 1 0 1 1 1449057 0 1449057 0.00380 17175750 0 17175750 0.04510 1020605 1020605 0.00270 19645412 19645412 0.05160 751704 317389 36000 281389 0.00070 1837 548509 548509 0.00140 79122 79122 0.00020 212679 205439 205439 0.00050 966220 1150459 36000 1114459 0.00280 966220 20795871 36000 20759871 0.05440 1 18475082 0 88275450 255587703 -167312253 X 1 1 68 1 ALTRU HOSPITAL

1200 S COLUMBIA RD GRAND FORKS ND 582066002

X X X 2 ALTRU REHABILITATION CENTER

1300 S COLUMBIA RD GRAND FORKS ND 582066002

X 3 ALTRU CLINIC - MAIN CLINIC

1000 S COLUMBIA RD GRAND FORKS ND 582066003

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 4 ALTRU CANCER CENTER

960 S COLUMBIA RD GRAND FORKS ND 582066003

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 5 TRUYU AESTHETIC CENTER

3165 DEMERS AVE GRAND FORKS ND 582066003

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 6 ALTRU CLINIC - FAMILY MEDICINE CENTER

1380 S COLUMBIA ROAD GRAND FORKS ND 582066003

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 7 GRAND FORKS FAMILY MEDICINE RESIDENCY

725 HAMLINE STREET GRAND FORKS ND 58203

OUTPATIENT CLINIC 8 GF FAMILY MEDICINE RESIDENCY PHARMACY

725 HAMLINE STREET GRAND FORKS ND 58203

OUTPATIENT PHARMACY 9 ALTRU CLINIC - DRAYTON

809 MAIN DRAYTON ND 582254650

OUTPATIENT CLINIC 10 ALTRU PSYCHIATRIC SERVICES

860 S COLUMBIA ROAD GRAND FORKS ND 582066002

OUTPATIENT DEPARTMENT - PSYCH SERVICES 11 ALTRU HOSPITAL - CENTER COURT FITNESS

1600 32ND AVE S GRAND FORKS ND 58201

OUTPATIENT THERAPY 12 ALTRU OUTREACH THERAPY

411 2ND ST NW EAST GRAND FORKS MN 56721

OUTPATIENT THERAPY 13 ALTRU HOSPITAL - OUTREACH WARREN

109 S MAIN ST WARREN MN 56762

OUTPATIENT THERAPY 14 ALTRU CLINIC - CAVALIER

201 E 3RD AVE S CAVALIER ND 582200040

OUTPATIENT CLINIC 15 ALTRU CLINIC - LAKE REGION

1001 7TH STREET NE DEVILS LAKE ND 583012719

OUTPATIENT CLINIC 16 ALTRU CLINIC - NEW ROCKFORD

6 8TH ST N NEW ROCKFORD ND 58356

OUTPATIENT CLINIC 17 ALTRU CLINIC - LAKOTA

608 4TH AVE SW HWY 2 LAKOTA ND 58344

OUTPATIENT CLINIC 18 ALTRU CLINIC - CROOKSTON

400 SOUTH MINNESOTA CROOKSTON MN 567160606

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 19 ALTRU CLINIC - RED LAKE FALLS

312 8TH ST SW RED LAKE FALLS MN 567504662

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 20 ALTRU CLINIC - ERSKINE

113 VANCE AVE N ERSKINE MN 565354201

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 21 ALTRU CLINIC - FERTILE

101 S MILL ST FERTILE MN 565404215

OUTPATIENT DEPT OF ALTRU HOSP - CLINIC 22 ALTRU CLINIC - ROSEAU

711 DELMORE DRIVE ROSEAU MN 567511534

OUTPATIENT CLINIC 23 ALTRU CLINIC - WARROAD

412 MAIN AVE NE WARROARD MN 567632342

OUTPATIENT CLINIC 24 ALTRU CLINIC - GREENBUSH

6TH MCKENZIE GREENBUSH MN 56726

OUTPATIENT CLINIC 25 ALTRU CLINIC - KARLSTAD

1ST ROOSEVELT KARLSTAD MN 56732

OUTPATIENT CLINIC 26 UNITY MEDICAL CENTER

164 WEST 13TH STREET GRAFTON ND 58237

HOME HEALTH/HOSPICE 27 FIRST CARE HEALTH CENTER

PO BOX I PARK RIVER ND 58270

HOME HEALTH/HOSPICE 28 UNION HOSPITAL

42 6TH AVE SE MAYVILLE ND 58257

HOME HEALTH/HOSPICE 29 NELSON COUNTY HEALTH SYSTEM

BOX 367 MCVILLE ND 58254

HOME HEALTH/HOSPICE 30 WARREN HOSPITAL

1ST ROOSEVELT KARLSTAD MN 56732

HOME HEALTH/HOSPICE 31 CO CAVALIER CLINIC

201 E 3RD AVE S CAVALIER ND 58220

HOME HEALTH/HOSPICE 32 ALTRU HOME SVCS-NORTH VALLEY HOME HEALTH

109 S MINNESOTA ST WARREN MN 56762

HOME HEALTH/HOSPICE 33 ANETA PARKVIEW HEALTH CENTER

BOX 287 ANETA ND 58212

OUTREACH CLINIC 34 CAVALIER COUNTY MEMORIAL

909 2ND ST LANGDON ND 58249

OUTREACH CLINIC 35 CENTRAL BOILER

20502 160TH ST GREENBUSH MN 56726

OUTREACH CLINIC 36 COOPERSTOWN MEDICAL CENTER

1200 ROBERTS ST COOPERSTOWN ND 58425

OUTREACH CLINIC 37 DEVILS LAKE GOOD SAMARITAN

302 7TH AVE DEVILS LAKE ND 58301

OUTREACH CLINIC 38 FIRST CARE HEALTH CENTER

115 VIVIAN ST PARK RIVER ND 58270

OUTREACH CLINIC 39 FRIENDSHIP

554 W 12TH ST GRAFTON ND 58327

OUTREACH CLINIC 40 4TH CORP

120 11TH ST NEW ROCKFORD ND 58356

OUTREACH CLINIC 41 GRIGGS COUNTY HOSPITAL

1200 ROBERTS AVE NE COOPERSTOWN ND 58425

OUTREACH CLINIC 42 HATTON PRAIRIE VILLAGE

930 DAKOTA AVE HATTON ND 58240

OUTREACH CLINIC 43 HEARTLAND CARE CENTER

620 14TH AVE NE DEVILS LAKE ND 58301

OUTREACH CLINIC 44 KARLSTAD HEALTH CARE

304 WASHINGTON AVE W KARLSTAD MN 56732

OUTREACH CLINIC 45 KITTSON MEMORIAL HEALTH CARE CENTER

1010 S BIRCH HALLOCK MN 56728

OUTREACH CLINIC 46 KITTSON MEMORIAL CLINIC OF KARLSTAD

1ST AND ROOSEVELT KARLSTAD MN 56732

OUTREACH CLINIC 47 LAKE REGION CORP

224 3RD ST NW DEVILS LAKE ND 583012908

OUTREACH CLINIC 48 LAKOTA GOOD SAMARITAN

608 4TH AVE SW HWY 2 LAKOTA ND 583447500

OUTREACH CLINIC 49 LAKOTA HEALTH CENTER

117 2 ST W LAKOTA ND 58344

OUTREACH CLINIC 50 LUTHER MEMORIAL HOME

750 MAIN ST MAYVILLE ND 58257

OUTREACH CLINIC 51 MADDOCK SCHOOL SYSTEM

PO BOX 398 MADDOCK ND 58348

OUTREACH CLINIC 52 MAPLE MANOR CARE CENTER

1116 9TH AVE LANGDON ND 58249

OUTREACH CLINIC 53 MCINTOSH MANOR NURSING HOME

600 RIVERSIDE AVE NE MCINTOSH MN 56556

OUTREACH CLINIC 54 MERCY HOSPITAL

1031 7TH ST NE DEVILS LAKE ND 58301

OUTREACH CLINIC 55 NELSON COUNTY CARE CENTER

108 E NYHUS AVE MCVILLE ND 58254

OUTREACH CLINIC 56 NELSON COUNTY HEALTH SYSTEM

200 NORTH MAIN MCVILLE ND 58254

OUTREACH CLINIC 57 NORTHWEST REGIONAL

PO BOX 9 NEWFOLDEN MN 56738

OUTREACH CLINIC 58 NORTHWOOD DEACONESS

4 N PART ST NORTHWOOD ND 58267

OUTREACH CLINIC 59 OAKLAND PARK COMMUNITIES INC

123 BAKEN STREET THEIF RIVER FALLS MN 56701

OUTREACH CLINIC 60 OAKLAND PARK NURSING HOME

123 BAKEN STREET THEIF RIVER FALLS MN 56701

OUTREACH CLINIC 61 PEMBILIER NURSING CENTER

500 DELANO AVE WALHALLA ND 58282

OUTREACH CLINIC 62 PEMBINA COUNTY MEMORIAL HOSPITAL

301 MOUNTAIN STREET E CAVALIER ND 58220

OUTREACH CLINIC 63 PIONEER MEMORIAL CARE CENTER

23028 347TH ST SE ERSKINE MN 565359466

OUTREACH CLINIC 64 REM-GRAFTON

817 HILL AVE GRAFTON ND 58327

OUTREACH CLINIC 65 UNION HOSPITAL

42 6TH AVE SE MAYVILLE ND 58257

OUTREACH CLINIC 66 VALLEY 4000

4004 24TH AVE SOUTH GRAND FORKS ND 58201

OUTREACH CLINIC 67 VALLEY MEMORIAL HOMES

2900 14TH AVE SOUTH GRAND FORKS ND 58201

OUTREACH CLINIC 68 WEDGEWOOD MANOR

804 MAIN STREET WEST CAVALIER ND 58220

OUTREACH CLINIC NA 1 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X 1 X X X X 1 X X X X X X 1 X 0 1 PART I, LINE 6A: PREPARATION OF ANNUAL COMMUNITY BENEFIT REPORT: ALTRU HEALTH SYSTEM PREPARES ANNUALLY A COMMUNITY BENEFIT REPORT BASED ON FORMS DESIGNED BY THE CATHOLIC HEALTH ORGANIZATION. ONCE ALL REPORTING FORMS HAVE BEEN COMPILED FOR THE YEAR, THE CATHOLIC HEALTH ORGANIZATION'S REFERENCE GUIDE FROM "A GUIDE FOR PLANNING AND REPORTING COMMUNITY BENEFIT" IS USED TO DETERMINE WHAT ITEMS SHOULD BE REPORTED INTO WHAT CATEGORY. THE COMMUNITY BENEFIT REPORT, IS PUBLISHED AS A PART OF THE CORPORATION'S ANNUAL REPORT, WHICH IS PLACED ON OUR WEB SITE FOR PUBLIC ACCESS. PART I, LINE 7: COLUMN (F) - PERCENT OF TOTAL EXPENSES: IN DETERMINING THE DENOMINATOR FOR THE PERCENT OF TOTAL EXPENSE CALCULATION, THE AMOUNT REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A) WAS REDUCED BY BAD DEBTS EXPENSE OF $18,475,082.CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST: THE METHODOLOGY USED TO DETERMINE THE REPORTED AMOUNTS FOR THE CHARITY CARE IS A COST-TO-CHARGE RATIO BASED ON GROSS CHARGES WRITTEN OFF PURSUANT TO OUR CHARITY CARE AND MEANS-TESTED PROGRAMS ELIGIBILITY CRITERIA. OTHER COMMUNITY BENEFIT IS DETERMINED FROM INFORMATION THAT WAS COMPILED ON FORMS DESIGNED BY THE CATHOLIC HEALTH ORGANIZATION AND USING THEIR REFERENCE GUIDE, "A GUIDE FOR PLANNING AND REPORTING COMMUNITY BENEFIT," TO DETERMINE WHICH CATEGORY THE AMOUNTS ARE PROPERLY REPORTED UNDER. PART II: NONE DOCUMENTED ON FORM 990. PART III, LINE 4: FOOTNOTE DISCLOSURE REGARDING BAD DEBTS EXPENSE: NOTES 1 AND 13 TO THE AUDITED FINANCIAL STATEMENTS REPORT ON BAD DEBT EXPENSE. NOTE 1 - "ACCOUNTS RECEIVABLE ARE CARRIED AT ORIGINAL AMOUNTS BILLED LESS AN ESTIMATE MADE FOR CONTRACTUAL DISCOUNTS AND DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL DISCOUNTS BY USING HISTORICAL EXPERIENCE APPLIED TO THE PAYOR SOURCE. ACCOUNTS RECEIVABLE ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS RECEIVABLE PREVIOUSLY WRITTEN OFF ARE RECORDED WHEN RECEIVED." NOTE 13 - "...NEITHER THE CHARITY CARE NOR THE UNCOMPENSATED CARE AMOUNTS INCLUDE BAD DEBTS AS SHOWN IN THE STATEMENT OF OPERATIONS." PART III, LINE 8: NONE OF THE SHORTFALL SHOWN ON PART III, LINE 7 OF $167,312,253 HAS BEEN TREATED AS COMMUNITY BENEFIT AS REPORTED ON SCHEDULE H. THE SOURCE OF THE AMOUNT SHOWN ON PART III, LINE 6 COMES FROM THE MEDICARE ALLOWABLE COSTS REPORTED IN ALTRU'S MEDICARE COST REPORT SUBMITTED FOR THE FISCAL YEAR ENDING DECEMBER 31, 2010, UTILIZING THE FOLLOWING WORKSHEETS: WORKSHEETS B PART I, H-7 PARTS 1&2, I-4, AND K-6. PART III, LINE 9B: PROVISION FOR COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE FOUND IN ALTRU'S POLICIES 2611 "DEDUCTIONS FROM REVENUES" AND 2614 "CHARITY CARE." ALTRU'S COMMUNITY CARE PROGRAM IS DESIGNED TO PROVIDE FINANCIAL ASSISTANCE TO THOSE WHO HAVE NO INSURANCE AND/OR LIMITED MEANS TO PAY FOR THEIR MEDICAL SERVICES AND DO NOT QUALIFY FOR OTHER PROGRAMS. IN ADDITION TO QUALITY HEALTHCARE, PATIENTS OF ALTRU HEALTH SYSTEM ARE PROVIDED FINANCIAL COUNSELING REGARDING THEIR MEDICAL BILLS, BY SOMEONE WHO CAN UNDERSTAND AND OFFER POSSIBLE SOLUTIONS FOR THOSE WHO CANNOT PAY IN FULL. PROGRAMS ARE ALSO AVAILABLE FOR UNINSURED PATIENTS, AND FOR THOSE FOUND TO BE IN MEDICAL HARDSHIP. N/A PART V, SECTION B, LINE 18C: GROSS CHARGES ARE NOT ADJUSTED FOR UNINSURED PATIENTS IN ER UNLESS THEY APPLY FOR AND QUALIFY FOR CHARITY CARE. N/A PART V, SECTION B, LINE 19D: GROSS CHARGES ARE NOT ADJUSTED FOR UNINSURED PATIENTS IN ER UNLESS THEY APPLY FOR AND QUALIFY FOR CHARITY CARE. N/A PART V, SECTION B, LINE 21: ALL PATIENTS ARE CHARGED THE GROSS CHARGE REGARDLESS OF INSURANCE STATUS. ADJUSTMENTS MAY BE APPLIED PROVIDING THE PATIENTS APPLY FOR AND QUALIFY FOR CHARITY CARE. PART VI, LINE 2: NEEDS ASSESSMENT: ALTRU HEALTH SYSTEM'S MISSION - IMPROVING HEALTH, ENRICHING LIFE - CONFIRMS THAT OUR RESPONSIBILITY TO THE REGION GOES BEYOND PROVIDING QUALITY HEALTHCARE SERVICES. ALL OF OUR RESOURCES ARE DEVOTED TO IMPROVING HEALTH IN THE COMMUNITIES WE SERVE. AT ALTRU, GOOD HEALTH MEANS THAT EVERY INDIVIDUAL SHOULD ENJOY THE BEST ACHIEVABLE AND SO SHOULD OUR COMMUNITIES. MOVING FORWARD, BECAUSE OF STIPULATIONS DEFINED IN THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, ALTRU WILL DEVELOP A FORMAL PROCESS FOR PERFORMING A COMMUNITY HEALTH NEEDS ASSESSMENT BASED ON OUR MISSION. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:ALTRU HAS SEVERAL AVENUES IN WHICH INFORMATION REGARDING FINANCIAL ASSISTANCE PROGRAMS IS COMMUNICATED TO PATIENTS. UNINSURED AND SELF-PAY PATIENTS IN THE HOSPITAL RECEIVE A VISIT FROM PATIENT REPRESENTATIVES AFTER INTAKE. DURING THIS MEETING, THEY ARE INFORMED OF VARIOUS FEDERAL, STATE AND COMMUNITY-BASED PROGRAMS THAT MAY PROVIDE ASSISTANCE. UNINSURED OR SELF-PAY PATIENTS FROM OUTPATIENTS RECEIVE CONTACT FROM PATIENT REPRESENTATIVES BY PHONE OR EMAIL INFORMING THEM OF POTENTIAL SOURCES OF FINANCIAL ASSISTANCE. BOTH SETS OF PATIENTS ARE ALSO PROVIDED INFORMATION ON HOW TO MOVE FORWARD IN APPLYING FOR THE PROGRAMS. IF PATIENTS ARE FOUND TO BE STRUGGLING WITH MEDICAL EXPENSES, OUR CREDIT AND COLLECTIONS REPRESENTATIVES UTILIZE LETTERS AND PHONE CALLS TO INFORM THEM OF VARIOUS RESOURCES THAT MAY PROVIDE ASSISTANCE.FINANCIAL ASSISTANCE INFORMATION IS ALSO AVAILABLE TO THE PUBLIC AS A WHOLE. ALTRU'S WEBSITE, ALTRU.ORG, INCLUDES FINANCIAL ASSISTANCE CONTACT INFORMATION AND ELIGIBILITY GUIDELINES. PATIENTS MAY REVIEW THIS ON THEIR OWN AND CONTACT AGENCIES THAT MAY PROVIDE ASSISTANCE BASED ON THEIR CIRCUMSTANCES. ALSO, ALTRU DISTRIBUTES BROCHURES FEATURING OUR COMMUNITY CARE PROGRAM AND OTHER FEDERAL AND STATE PROGRAMS. THESE BROCHURES ARE AVAILABLE TO BOTH PATIENTS AND VISITORS IN WAITING ROOMS OF OUR INPATIENT AND OUTPATIENT FACILITIES AS WELL AS IN ALL BUSINESS OFFICE LOCATIONS. PART VI, LINE 4: COMMUNITY INFORMATION:ALTRU HEALTH SYSTEM SERVES A 17-COUNTY AREA THAT IS DIVIDED INTO THREE DISTINCT SERVICE AREAS (PRIMARY, SECONDARY, AND REFERRAL) AND HAS A POPULATION OF 219,405 PERSONS (2011 ESTIMATE) WHO RESIDE IN A DIVERSE AREA OF AGRICULTURE AND INDUSTRY. THE SERVICE AREA STRETCHES 265 MILES EAST AND WEST AND 120 MILES NORTH AND SOUTH. GRAND FORKS SITS IN THE MIDDLE OF THE RED RIVER VALLEY, ONE OF THE WORLD'S RICHEST AGRICULTURAL AREAS. PRINCIPAL CROPS INCLUDE SUGAR BEETS, POTATOES, EDIBLE BEANS, AND SMALL GRAINS SUCH AS WHEAT AND BARLEY. MUCH OF THE INDUSTRY IN THE AREA IS RELATED TO AGRICULTURE AND FOOD PROCESSING.THE PRIMARY SERVICE AREA, COMPRISED OF GRAND FORKS COUNTY (NORTH DAKOTA) AND EAST GRAND FORKS (MINNESOTA), IS HOME TO 77,215 PEOPLE (2011 ESTIMATE). LOCATED IN THIS MARKET IS ALTRU HOSPITAL, ALTRU REHABILITATION CENTER, ALTRU CANCER CENTER, AND SIX OTHER LOCATIONS THAT ARE HOME TO OUR PROVIDERS' CLINIC PRACTICES AND OTHER SERVICES OFFERED BY ALTRU. ALTRU HOSPITAL SERVES AS THE MAJOR REFERRAL CENTER FOR THE PEOPLE OF THE REGION. AS SUCH, IT PROVIDES A BROAD SPECTRUM OF PROGRAMS AND SERVICES. A FULL RANGE OF SERVICES ARE AVAILABLE FOR PATIENTS SUFFERING FROM CANCER, HEART DISEASE, END-STAGE RENAL DISEASE, NEUROLOGICAL DISORDERS, ALCOHOL OR CHEMICAL DEPENDENCY, HIGH RISK OBSTETRICAL COMPLICATIONS, AND PSYCHIATRIC DISORDERS. ALTRU HOSPITAL'S INPATIENT MARKET SHARE IN 2010 FOR OUR PRIMARY MARKET WAS 82 PERCENT BASED ON CLAIMS DATA FROM BLUE CROSS BLUE SHIELD OF NORTH DAKOTA. ALMOST 80 PERCENT OF THE PHYSICIANS IN THE PRIMARY AREA ARE EMPLOYED BY ALTRU HEALTH SYSTEM. ALSO LOCATED IN GRAND FORKS COUNTY IS NORTHWOOD COMMUNITY HEALTH CENTER (IN NORTHWOOD, ND). A COUPLE NOTABLE POPULATIONS ALTRU SERVES THAT ARE LOCATED IN OUR PRIMARY SERVICE AREA INCLUDE THE UNIVERSITY OF NORTH DAKOTA AND GRAND FORKS AIR FORCE BASE. THE UNIVERSITY OF NORTH DAKOTA IS THE STATE'S OLDEST INSTITUTION OF HIGHER LEARNING WITH AN ENROLLMENT OF ABOUT 14,700 STUDENTS. THE NUMBER OF RESIDENTS AT GRAND FORKS AIR FORCE BASE WAS COUNTED AT 2,367 IN THE 2010 CENSUS.WITH A POPULATION OF 57,111 (2011 ESTIMATE), THE SECONDARY SERVICE AREA IS COMPRISED OF SIX COUNTIES TO THE WEST, NORTH, AND EAST OF GRAND FORKS COUNTY: NELSON, WALSH, AND PEMBINA COUNTIES IN NORTH DAKOTA, AND POLK, MARSHALL, AND KITTSON COUNTIES IN MINNESOTA; THIS AREA IS LARGELY RURAL AND AGRICULTURAL. WITHIN THIS AREA, ALTRU HAS FIVE REGIONAL CLINIC LOCATIONS; IT IS ALSO HOME TO SEVERAL SMALL HOSPITALS AS LISTED BELOW.SECONDARY SERVICE AREA HOSPITALS: LOCATIONUNITY MEDICAL CENTER: GRAFTON, NDFIRST CARE HEALTH CENTER: PARK RIVER, NDPEMBINA COUNTY MEMORIAL HOSPITAL: CAVALIER, NDNELSON COUNTY HEALTH SYSTEM: MCVILLE, NDKITTSON MEMORIAL HOSPITAL: HALLOCK, MNNORTH VALLEY HEALTH CENTER: WARREN, MNRIVERVIEW HOSPITAL: CROOKSTON, MNESSENTIA HEALTH: FOSSTON, MNIN 2010, ALTRU'S HOSPITAL MARKET SHARE IN THIS SERVICE AREA WAS AROUND 53 PERCENT ACCORDING TO CLAIMS PAID BY BLUE CROSS BLUE SHIELD OF NORTH DAKOTA. THE SYSTEM EMPLOYS MANY OF THE PHYSICIANS IN THE SECONDARY SERVICE AREA. ALL OF THESE PHYSICIANS ARE ON MEDICAL STAFFS OF COMMUNITY HOSPITALS THROUGHOUT THE REGION, AND REFER PATIENTS TO GRAND FORKS AND ELSEWHERE FOR SPECIALTY CARE.THE SYSTEM'S REFERRAL AREA IS COMPRISED OF TEN COUNTIES ENCIRCLING THE PRIMARY AND SECONDARY SERVICE AREAS (ROLETTE, TOWNER, BENSON, RAMSEY, CAVALIER, AND TRAILL COUNTIES IN NORTH DAKOTA AND ROSEAU, LAKE OF THE WOODS, PENNINGTON, AND RED LAKE COUNTIES IN MINNESOTA.) THIS REGION IS ALSO MOSTLY RURAL AND AGRICULTURAL AND INCLUDES SEVERAL SMALLER HOSPITALS AS LISTED SERVING THE PRIMARY CARE NEEDS OF THEIR COMMUNITIES. ALTRU HAS FIVE REGIONAL CLINICS IN THIS SERVICE AREA AND ALTRU HOSPITAL'S INPATIENT MARKET SHARE IN THIS REGION IS ABOUT 21 PERCENT ACCORDING TO 2010 CLAIMS PAID BY BLUE CROSS BLUE SHIELD OF NORTH DAKOTA. ALTRU, ONCE AGAIN, EMPLOYS MANY OF THE PHYSICIANS IN THIS AREA, AND THESE PHYSICIANS HAVE PRACTICE PATTERNS SIMILAR TO THOSE OF THE PHYSICIANS IN OUR SECONDARY SERVICE AREA.REFERRAL SERVICE AREA HOSPITALS: LOCATIONCAVALIER COUNTY MEMORIAL HOSPITAL: LANGDON, NDHILLSBORO MEDICAL CENTER: HILLSBORO, NDLAKEWOOD HEALTH CENTER: BAUDETTE, MNMERCY HOSPITAL: DEVILS LAKE, NDSANFORD-THIEF RIVER FALLS MEDICAL CENTER: THIEF RIVER FALLS, MNPRESENTATION MEDICAL CENTER: ROLLA, NDTOWNER COUNTY MEDICAL CENTER: CANDO, NDSANFORD MAYVILLE MEDICAL CENTER: MAYVILLE, NDLIFECARE MEDICAL CENTER: ROSEAU, MNQUENTIN N. BURDICK MEMORIAL HOSPITAL: BELCOURT, NDAS PREVIOUSLY MENTIONED, ALTRU'S 17-COUNTY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 219,000. USING DATA FROM THOMSON REUTERS (A VENDOR SPECIALIZING IN HEALTH CARE PLANNING INFORMATION), THE INSURANCE COVERAGE FOR COMMUNITIES IN OUR SERVICE AREA IS ESTIMATED TO BE AS FOLLOWS: COVERAGE ESTIMATES AS A PERCENTMEDICAID 22,978 11%MEDICARE 31,437 15%DUAL ELIGIBLE 4,145 2%PRIVATE EMPLOYER SPONSORED 108,122 51%PRIVATE DIRECT 18,342 9%UNINSURED 28,749 13%A PERCENTAGE BREAKDOWN OF INPATIENT UTILIZATION FOR ALTRU HOSPITAL BASED ON DISCHARGES BY TYPE OF PAYER IN 2010 SHOWS APPROXIMATELY 11 PERCENT OF DISCHARGES WERE FOR MEDICAID AND 13 PERCENT WERE SELF PAY (UNINSURED). ALSO FROM THOMSON REUTERS, OUR TOTAL SERVICE AREA'S INCOME BY HOUSEHOLD IS AS FOLLOWS:INCOME RANGE 2011 HOUSEHOLDS$ 0 - $ 9,999 8,101$ 10,000 - $ 14,999 4,975$ 15,000 - $ 19,999 5,556$ 20,000 - $ 24,999 5,436$ 25,000 - $ 29,999 6,013$ 30,000 - $ 34,999 5,807$ 35,000 - $ 39,999 5,512$ 40,000 - $ 44,999 5,141$ 45,000 - $ 49,999 4,874$ 50,000 - $ 59,999 8,907$ 60,000 - $ 74,999 9,975$ 75,000 - $ 99,999 8,772$100,000 - $124,999 4,155$125,000 - $149,999 1,588$150,000 - $199,999 1,123$200,000 - $249,999 615$250,000 - $499,999 412$500,000 + 170ACCORDING TO THE WEBSITE FOR HEALTH RESOURCES AND SERVICES ADMINISTRATION, THE FOLLOWING AREAS IN OUR SERVICE AREA ARE MUA'S:NORTH DAKOTA:BENSON COUNTY: BENSON SERVICE AREACAVALIER COUNTY: CAVALIER SERVICE AREAGRAND FORKS COUNTY: NORTHWOOD SERVICE AREA, GRAND FORKS SERVICE AREANELSON COUNTY: NELSON SERVICE AREAPEMBINA COUNTY: WALHALLA SERVICE AREAROLETTE COUNTY: ROLETTE SERVICE AREATOWNER COUNTY: CANDO CITY SERVICE AREATRAILL COUNTY: TRAILL SERVICE AREAWALSH COUNTY: PARK RIVER SERVICE AREAMINNESOTA:KITTSON COUNTY: KITTSON SERVICE AREAMARSHALL COUNTY: MARSHALL SERVICE AREAPOLK COUNTY: POLK SERVICE AREARED LAKE COUNTY: RED LAKE SERVICE AREAROSEAU COUNTY: ROSEAU SERVICE AREA PART VI, LINE 6: ALL OF ALTRU'S RESOURCES ARE DEVOTED TO IMPROVING HEALTH IN THE COMMUNITIES WE SERVE. TO DO SO, WE KNOW THAT NOT ALL MEDICAL SERVICES WILL COME FROM STAFF EMPLOYED BY ALTRU HEALTH SYSTEM. ALTRU EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN OUR COMMUNITY FOR NEARLY ALL DEPARTMENTS. ALSO, OUR BOARD OF DIRECTORS IS MADE UP OF INDIVIDUALS FROM OUTSIDE ALTRU HEALTH SYSTEM. THESE PEOPLE ARE VOLUNTEERS WHO HAVE THE SAME DEDICATION AND FOCUS ON ALTRU'S MISSION AS OUR OWN STAFF. PART VI, LINE 7: ALTRU HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM.PART VI, LINE 8: ALTRU HEALTH SYSTEM IS NOT REQUIRED TO FILE OUR COMMUNITY BENEFIT REPORT WITH ANY OUTSIDE ORGANIZATIONS BUT HAS MADE OUR REPORT AVAILABLE TO ANYONE ON OUR WEB SITE. 1 COMMUNITY VIOLENCE INTERVENTION CENTER 211 S 4TH ST STE 207 GRAND FORKS ND 58201 450359167 501(C)(3) 7500 PLEDGE FOR DREAM MAKER SOCIETY UNIVERSITY OF NORTH DAKOTA FOUNDATION 3100 UNIVERSITY AVE STOP 8157 GRAND FORKS ND 58202 450348296 501(C)(3) 9810 STUDENT SCHOLARSHIP FUND UNITED WAY 1402 24TH AVE S STE 400 GRAND FORKS ND 58201 450255772 501(C)(3) 10000 CORPORATE SPONSORSHIP OF UNITED WAY 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: UNIVERSITY OF NORTH DAKOTA FOUNDATION - SCHOLARSHIPS ARE DIRECTED BY THE UND FOUNDATION AS PART OF THE UND SCHOLARSHIP PROGRAM AND ALTRU DOES NOT DIRECTLY DESIGNATE SCHOLARSHIP RECIPIENTS. COMMUNITY VIOLENCE INTERVENTION CENTER - FUNDS WERE GRANTED WITH THE DIRECTION THAT CVIC WAS ABLE TO USE FUNDS AS NEEDED. CVIC DETERMINES THE RECIPIENTS OF THE ASSISTANCE PROVIDED THROUGH THOSE FUNDS. UNITED WAY - FUNDS ARE USED BY UNITED WAY AS PART OF THE BUILDING BLOCKS PROGRAM. UNITED WAY'S BOARD DETERMINES USE OF THE FUNDS UNDER THEIR ALLOCATION PROCESS. X X X X X X 1 1 0 0 0 0 0 0 0 DONALD DEBELTZ MD 445250 0 0 0 12344 0 22387 0 8603 0 488584 0 0 0 JAMES HARGREAVES DO 393168 0 0 0 12483 0 22387 0 4079 0 432117 0 0 0 MATTHEW ROLLER MD 390189 0 0 0 10852 0 22387 0 6954 0 430382 0 0 0 CASEY RYAN MD 443358 0 0 0 12343 0 22387 0 4603 0 482691 0 0 0 DAVID MOLMEN 377857 0 0 0 12295 0 22387 0 7603 0 420142 0 0 0 TIMOTHY P SAYLER 261788 0 0 0 11913 0 18814 0 7603 0 300118 0 0 0 DWIGHT THOMPSON 306096 0 0 0 12162 0 22387 0 8603 0 349248 0 0 0 JAMES VANLOOY MD 284779 0 0 0 11306 0 22387 0 4503 0 322975 0 0 0 MARGARET REED RN 201142 0 0 0 2155 0 14078 0 1000 0 218375 0 0 0 RENEE M AXTMAN RN 177867 0 0 0 11286 0 12962 0 5000 0 207115 0 0 0 ROBERT THOMPSON MD MBA 192088 0 0 0 7720 0 0 0 0 0 199808 0 27754 0 LELAND LINDQUIST 215536 0 0 0 11557 0 15304 0 1950 0 244347 0 0 0 JACQUELYN WALSH 161711 0 0 0 10481 0 11569 0 0 0 183761 0 0 0 DENNIS REISNOUR 178812 0 0 0 1943 0 12648 0 3250 0 196653 0 0 0 KENNETH VEIN 164092 0 0 0 10669 0 11826 0 1950 0 188537 0 0 0 MARK WAIND 159197 0 0 0 8549 0 11374 0 1200 0 180320 0 0 0 BRADLEY WEHE 170185 0 0 0 11166 0 12401 0 3900 0 197652 0 0 0 KERRY P CARLSON 151046 0 0 0 11024 0 11002 0 3000 0 176072 0 0 0 KELLY HAGEN RN 144839 0 0 0 10365 0 7808 0 5000 0 168012 0 0 0 CYNTHIA BRASETH 95543 0 0 0 80879 0 2099 0 2589 0 181110 0 0 0 MOHAMED CHEBACLO 1014375 0 0 0 11811 0 22387 0 2000 0 1050573 0 0 0 MICKEY SYRQUIN 1062810 0 0 0 11557 0 22387 0 0 0 1096754 0 0 0 IKECHUKWU ONYEKA 935836 0 0 0 11811 0 22387 0 4200 0 974234 0 0 0 RONALD BROCKMAN 863642 0 0 0 12486 0 22387 0 2800 0 901315 0 0 0 ABDEL AHMED 1607462 0 0 0 12486 0 22387 0 5000 0 1647335 0 0 0 PART I, LINES 4A-B CYNTHIA BRASETH RECEIVED SEVERANCE PAY OF $75,318. ROBERT THOMPSON, MD, MBA, BOARD MEMBER AND ADMINISTRATIVE MEDICAL DIRECTOR, RECEIVED A DISTRIBUTION FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN OF $27,754. CITY OF GRAND FORKS 456002085 38546WAW0 2005-12-01 40000000 CAPITAL EXPENDITURES, FUND DEBT SERVICE FUND 0 0 0 CITY OF GRAND FORKS 456002085 38546WAZ3 2007-08-15 30755173 REFUND BONDS ISSUED JUNE 17, 1997 AND MARCH 23, 2000 0 0 0 CITY OF GRAND FORKS 456002085 2010-08-20 30000000 CAPITAL EXPENDITURES, FUND DEBT SERVICE FUND 0 0 0 40000000 3530596 425000 1506870 34537534 2007 0 0 1 1 30755173 3075517 27283893 395763 2007 1 0 1 1 30000000 203750 17030360 12765890 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 DARRELL LARSON ESQ BOARD CHAIR 19925 PROFESSIONAL SERVICES PROVIDED TO THE ORGANIZATION THROUGH A BUSINESS RELATIONSHIP - LEGAL FILE #4322 0 DARRELL LARSON ESQ BOARD CHAIR 3896 PROFESSIONAL SERVICES PROVIDED TO THE ORGANIZATION THROUGH A BUSINESS RELATIONSHIP - LEGAL FILE #1187 0 DARRELL LARSON ESQ BOARD CHAIR 2004 PROFESSIONAL SERVICES PROVIDED TO THE ORGANIZATION THROUGH A BUSINESS RELATIONSHIP - LEGAL FILE #0676 0 DARRELL LARSON ESQ BOARD CHAIR 125421 PROFESSIONAL SERVICES PROVIDED TO THE ORGANIZATION THROUGH A BUSINESS RELATIONSHIP - LEGAL FILE #1183 0 FORM 990, PART VI, SECTION A, LINE 2 CFO/TREASURER, DWIGHT THOMPSON, HAS A FAMILY RELATIONSHIP WITH KEY EMPLOYEE, ROBERT THOMPSON, MD MBA. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED FOR ACCURACY BY THE BOARD OF DIRECTORS AND APPROVED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY IS REVIEWED AND SIGNED OFF ANNUALLY BY ALL MEMBERS OF THE BOARD OF DIRECTORS. THESE FORMS ARE COLLECTED AND REVIEWED BY THE SECRETARY. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF THE COMPENSATION FOR THE PRESIDENT AND CEO ARE DETERMINED BY THE BOARD. SUBSTANTIATION OF THESE DISCUSSIONS APPEAR IN THE BOARD MINUTES. COMPENSATION OF KEY EMPLOYEES ARE DETERMINED BY A COMPENSATION COMMITTEE FORMED OF PHYSICIANS THAT REPORT TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATIONS 990 AND 990-T PUBLIC INSPECTION COPIES ARE AVAILABLE UPON REQUEST. FORM 1023 IS AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC THROUGH PUBLISHED ANNUAL REPORTS AND VIA ITS WEB SITE. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,352,734. APPLICATION OF FASB ASC TOPIC 715 95,667. UNREALIZED IMPAIRMENT LOSS -44,531. TOTAL TO FORM 990, PART XI, LINE 5: 6,403,870. "DOING BUSINESS AS" CONTINUATION HEADING ITEM C ALTRU CLINIC-MAIN, ALTRU REHAB CENTER, ALTRU CANCER CENTER, ALTRU FAMILY MEDICINE CENTER, ALTRU FAMILY MEDICINE RESIDENCY, TRUYU AESTHETIC CENTER, ALTRU CLINIC-LAKE REGION, ALTRU CLINIC-CAVALIER, ALTRU CLINIC-DRAYTON, ALTRU CLINIC-CROOKSTON, ALTRU CLINIC-RED LAKE FALLS, ALTRU CLINIC-FERTILE, ALTRU CLINIC-ERSKINE, ALTRU CLINIC-ROSEAU, ALTRU CLINIC-WARROAD, ALTRU CLINIC-GREENBUSH, ALTRU CLINIC-KARLSTAD SCHEDULE 1 - PROGRAM SERVICE REVENUE DETAIL FORM 990, PART VIII, LINE 2B & 2D EXCLUSION AMOUNT BIOMED SERVICES $39,989 SITE SERVICE FEES $5,663 SUBTOTAL $45,652 CAFETERIA RECEIPTS $1,082,586 PHARMACY SALES TO EMPLOYEES $2,138 HOUSING/SPACE RENTALS $173,779 VENDING MACHINE INCOME $21,177 SALE OF SCRAP $6,225 SUBTOTAL $1,285,905 TOTAL EXCLUSION AMOUNT $1,331,557 RELATED OR EXEMPT FUNCTION INCOME CEPT REVENUE $126,000 HEARING CENTER $692,084 OCCUPATIONAL HEALTH $421,385 VHA SUPPLY CO - DISTRIBUTION $510,364 PURCHASE DISCOUNTS $48,230 REBATES $23,010 CONTRACT SERVICES, OUTREACH, EDUCATION $2,865,252 CPE FUND $6,500 MEDICAL RECORDS TRANSCRIPT FEES $155,671 AFFILIATED OTHER REVENUE $351,040 MISCELLANEOUS REVENUE $1,843,955 TOTAL RELATED/EXEMPT INCOME $7,043,491 SCHEDULE 2-PROGRAM SERVICE REVENUE DESCRIPTIONS FORM 990, PART VIII, LINE 2B & 2D 1. CAFETERIA RECEIPTS: REVENUE INCURRED THROUGH THE PROVISION OF MEALS FOR EMPLOYEES WHO HAVE TO BE IN THE BUILDING DURING THEIR REGULAR WORKDAY. PURPOSE: PROVIDE THESE EMPLOYEES WITH A PLACE TO ACQUIRE AND CONSUME THEIR MEALS; NO ALTERNATIVES ARE AVAILABLE. 2. BIOMED SERVICES: REVENUE EARNED THROUGH THE PROVISION OF SERVICES TO AREA HEALTH CARE FACILITIES NEEDING TO KEEP THEIR EQUIPMENT IN OPERATION IN ORDER TO PROVIDE THEIR PATIENTS WITH THEIR SERVICE. THE BIOMED PROGRAM PROVIDES SMALL REGIONAL HOSPITALS WITH A SERVICE OTHERWISE UNOBTAINABLE FROM ANYONE IN THE LOCAL AREA; IT IS OFTEN ON A PRIORITY BASIS. 3. PHARMACY SALES TO EMPLOYEES: REVENUE INCURRED IN SALES STRICTLY FOR THE CONVENIENCE OF EMPLOYEES. 4. HOUSING/SPACE RENTALS: INCOME INCURRED THROUGH THE RENTAL OF SPACE TO THE AREA HEALTH EDUCATION CENTER WHICH IS REQUIRED TO BE ON-SITE TO WORK WITH OUR PHYSICIANS PROVIDING HEALTH CARE TO PATIENTS. 5. CEPT REVENUE: REVENUE EARNED FROM THE EVALUATION AND TREATMENT OF ADOLESCENTS THROUGH A MULTI-DISCIPLINARY APPROACH INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH PATHOLOGY, AND PSYCHOLOGY. 6. HEARING CENTER: REVENUE FROM THE PROVISION OF AUDIOLOGICAL SERVICES AND HEARING AIDS TO PATIENTS. 7. OCCUPATIONAL HEALTH: FEES FOR PROVIDING DRUG SCREENINGS FOR REGIONAL EMPLOYERS. 8. VHA SUPPLY DISTRIBUTION: REBATE RECEIVED BASED ON VOLUME OF SUPPLY PURCHASES. 9. PURCHASE DISCOUNTS: THIS FIGURE REPRESENTS COST SAVINGS ON PURCHASES FROM SUPPLIERS FOR GOODS USED IN THE PROVISION OF HEALTH CARE SERVICES. 10. REBATES: REBATES RECEIVED BASED ON VOLUME OF PHARMACY PURCHASES. 11. SITE SERVICE FEES: FEES CHARGED FOR PROVIDING GROUNDS AND MAINTENANCE FOR THE AREA SURROUNDING THE UNITED HOSPITAL, INCLUDING FEES FOR SUCH SERVICES AS MAINTENANCE OF HOSPITAL PARKING LOT, SNOW SHOVELING, AND SNOW REMOVAL. 12. VENDING MACHINE INCOME: INCOME EARNED THROUGH THE OPERATION OF VENDING MACHINES IN THE BUILDINGS. 13. CONTRACT SERVICES, OUTREACH, EDUCATION: REVENUES EARNED IN THE PROVISION OF COMMUNITY EDUCATION/WELLNESS PROGRAMS, PASTORAL COUNSELING SERVICES, AND CONTRACTED SERVICES WITH REGIONAL HEALTHCARE SYSTEMS TO BRING OUTREACH SERVICES INTO THEIR COMMUNITIES. 14. CPE FUND: CLINICAL PASTORAL EDUCATION INCOME FROM PASTORAL RESIDENTS. PROGRAM SPONSORED BY THE ASSOCIATION OF CLINICAL PASTORAL EDUCATION. 15. MEDICAL RECORD TRANSCRIPTION FEES: INCOME EARNED THROUGH THE CHARGING OF VARIOUS THIRD PARTY PAYERS FOR THE PHOTOCOPYING OF PATIENT RECORDS. INSURANCE COMPANIES AND PAYERS ARE CHARGED TO OFFSET THE COST OF COPYING. 16. SALE OF SCRAP: INCOME EARNED THROUGH THE SALE OF ITEMS THAT ARE NOT FIXED ASSETS AND ARE OF DIMINISHED USE TO THE ORGANIZATION. 17.OTHER REVENUE CHARGED TO AFFILIATED CORPORATIONS: REVENUE FROM THE PROVISION OF PATIENT SERVICES, SUCH AS PSYCH OR LABORATORY, TO THE PATIENTS OF OTHER CORPORATIONS, WHICH ARE AFFILIATED TO ALTRU HEALTH SYSTEM. 18. MISCELLANEOUS INCOME: INCLUDES PRINCIPALLY A RETURN OF EXPENSES FROM AN INSURANCE POOL. ALSO INCLUDES INCOME EARNED THROUGH THE PROVISION OF SERVICES THAT ARE OPERATING IN THE HOSPITAL IN NATURE, BUT HAVE NO SPECIFIC COST CENTER IDENTIFICATIONS. AN EXAMPLE OF THIS WOULD BE IF THE DIRECTOR OF THE COMMUNICATIONS DEPARTMENT RECEIVED A SMALL TOKEN AMOUNT FOR FILLING OUT A SURVEY FROM SOME HEALTH CARE ORGANIZATION. ALTRU HEALTH FOUNDATION 2501 DEMERS AVE GRAND FORKS ND 58201 450368330 FUNDRAISING ND 501(C)(3) LINE 11A, I N/A 0 ALTRU HEALTH RESOURCES 1200 S COLUMBIA RD GRAND FORKS ND 58201 450368332 CONGREGATE HOUSING, ASSISTED LIVING ND 501(C)(3) LINE 11A, I N/A 0 DAK-MINN BLOOD BANK 1200 S COLUMBIA RD GRAND FORKS ND 58201 363453164 BLOOD BANK ND 501(C)(3) LINE 11D, III-O N/A 0 ALTRU ALLIANCE 1200 S COLUMBIA RD GRAND FORKS ND 58201 237389089 SUPPORT HOSPITAL AND AFFILIATES ND 501(C)(3) LINE 11B, II N/A 0 ALTRU SPECIALTY SERVICES INC 1200 S COLUMBIA RD GRAND FORKS ND 58201 450395652 DME SALES, RETAIL PHARMACY ND N/A C 1 0 1 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 ALTRU HEALTH FOUNDATION C 643934 FAIR MARKET VALUE ALTRU HEALTH RESOURCES D 143945 FAIR MARKET VALUE ALTRU SPECIALTY SERVICES A 185940 FAIR MARKET VALUE DAK-MINN BLOOD BANK C 116911 FAIR MARKET VALUE DAK-MINN BLOOD BANK N 356278 FAIR MARKET VALUE ALTRU ALLIANCE P 58556 FAIR MARKET VALUE ALTRU HEALTH RESOURCES A 2911 FAIR MARKET VALUE