2011-08-03T09:09:14-05:00 2010-12-31 990 2010-01-01 390980343 MAYO CLINIC HEALTH SYSTEM-CHIPPEWA VALLEY INC MAYO 5075381297 1501 THOMPSON STREET BLOOMER WI 54724 EDWARD WITTROCK 7158386465 2011-08-03 2010 2016-03-07 17:11:31Z FKA BLOOMER MEMORIAL MEDICAL CENTER EDWARD WITTROCK 1501 THOMPSON STREET BLOOMER WI 54724 31336626 0 X WWW.LUTHERMIDELFORTCHIPPEWAVALLEY.ORG X 1959 WI HOSPITAL WITH ATTACHED NURSING HOME AND THREE CLINICS. 11 5 369 47 0 0 128191 95892 30533697 31053590 55361 45745 86953 82223 30804202 31277450 6590 9987 0 0 16322587 19476902 0 0 7124 12368694 9725099 28697871 29211988 2106331 2065462 19854694 22340644 5134642 5468772 14720052 16871872 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 23026307 0 28751556 PATIENT CARE (SCHEDULE O)PATIENT CARE: BLOOMER MEMORIAL MEDICAL CENTER -- MAYO HEALTH SYSTEM (D/B/A LUTHER MIDELFORT CHIPPEWA VALLEY (LMCV)) IS A MEMBER OF THE MAYO HEALTH SYSTEM. EFFECTIVE MAY 23, 2011 THE FILING ORGANIZATION CHANGED ITS LEGAL NAME TO MAYO CLINIC HEALTH SYSTEM--CHIPPEWA VALLEY. MAYO HEALTH SYSTEM IS A FAMILY OF CLINICS, HOSPITALS AND HEALTH CARE FACILITIES SERVING COMMUNITIES IN MINNESOTA, IOWA AND WISCONSIN. AS PART OF MAYO CLINIC, MAYO HEALTH SYSTEM OFFERS OUTSTANDING CARE CLOSE TO HOME. PHYSICIANS AND STAFF IN MAYO HEALTH SYSTEM HAVE READY ACCESS TO THE KNOWLEDGE, RESOURCES, AND EXPERTISE OF MAYO CLINIC, YET CAN MEET PATIENTS' HEALTH CARE NEEDS LOCALLY. MAYO HEALTH SYSTEM IS PART OF THE COMMUNITY, FOCUSED ON IMPROVING THE HEALTH OF THE COMMUNITIES IN WHICH WE LIVE AND WORK. MAYO HEALTH SYSTEM TEAMS WITH MAYO CLINIC TO DELIVER UNPARALLELED HEALTH CARE TO COMMUNITIES THROUGH AN INTEGRATED NETWORK OF CLINICS AND HOSPITALS.MAYO HEALTH SYSTEM SITES EMPLOY APPROXIMATELY 800 PHYSICIANS AND 13,000 ALLIED HEALTH STAFF. IN ADDITION, MAYO CLINIC PHYSICIANS FROM MULTIPLE SPECIALTIES REGULARLY SEE PATIENTS AT THE MAYO HEALTH SYSTEM FACILITIES. BESIDES HAVING HEALTH CARE FACILITIES IN 70 COMMUNITIES, THE SYSTEM INCLUDES 17 OWNED HOSPITALS, SEVEN OWNED NURSING HOMES, PHYSICIAN SERVICE AGREEMENTS WITH THREE ADDITIONAL HOSPITALS, AND CONTRACT MANAGEMENT AGREEMENTS WITH TWO ADDITIONAL HOSPITALS AND ONE NURSING HOME. SINCE ITS INCEPTION IN 1992, MAYO HEALTH SYSTEM HAS GROWN FROM A NEW IDEA TO ONE OF THE MOST SUCCESSFUL REGIONAL HEALTH CARE SYSTEMS IN AMERICA. MAYO HEALTH SYSTEM COMPLETES MORE THAN TWO-MILLION PATIENT VISITS ANNUALLY. IT ALSO SERVES AS A NATIONAL LEADER IN QUALITY AND SAFETY EFFORTS BEING RECOGNIZED SIX TIMES BY THE AMERICAN MEDICAL GROUP ASSOCIATION'S ACCLAIM AWARD PROGRAM (2005 ACCLAIM AWARD RECIPIENT AND FIVE-TIME ACCLAIM AWARD HONOREE). THE ACCLAIM AWARDS HONOR PHYSICIAN-LED ORGANIZATIONS DELIVERING CARE ALIGNED WITH THE IDEAL DELIVERY MODEL WHERE PATIENTS EXPERIENCE SAFE, RELIABLE, RESPONSIVE, READILY AVAILABLE AND INTEGRATED CARE. IN ADDITION, THE MINNESOTA COUNCIL FOR QUALITY HAS RECOGNIZED MAYO HEALTH SYSTEM THREE TIMES FOR ITS PERFORMANCE EXCELLENCE EFFORTS. INDIVIDUAL MAYO HEALTH SYSTEM LOCATIONS HAVE ALSO BEEN HONORED FOR THEIR COMMITMENT TO QUALITY, SAFETY, SERVICE, PERFORMANCE AND THEIR COMMUNITIES.PEOPLE IN MINNESOTA, IOWA AND WISCONSIN CAN HAVE PEACE OF MIND KNOWING THAT MAYO HEALTH SYSTEM AND MAYO CLINIC PARTNER TO ENSURE HEALTHIER LIVES IN THE REGION.AS OUR MISSION STATES, LMCV'S MISSION IS 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. LMCV'S VISION IS TO ACHIEVE THE HIGHEST STANDARDS FOR MEDICAL CARE AND HEALTH IMPROVEMENT IN THE COMMUNITIES IN WHICH WE LIVE AND WORK. OUR FIRST PRIORITY IS TO MEET PATIENT NEEDS GUIDED BY THE CORE VALUES OF INTEGRITY, CONTINUOUS IMPROVEMENT, SERVICE, TEAMWORK, INNOVATION, BALANCE AND FINANCIAL INTEGRITY. LMCV OPERATES ON A NONDISCRIMINATORY BASIS, REGARDLESS OF RACE, COLOR, SEX, RELIGION OR NATIONAL ORIGIN.BLOOMER HOSPITAL: THE HOSPITAL PLAYS A VITAL ROLE IN THE HEALTH AND WELL BEING OF THE COMMUNITY BY OFFERING SERVICES SUCH AS 24-HOUR EMERGENCY CARE, SAME DAY SURGERY, PT/OT/RT/SPEECH THERAPY, PULMONARY REHABILITATIVE SERVICES, CARDIAC REHABILITATIVE TREATMENTS, AND ADVANCED DIAGNOSTIC TECHNOLOGY. THE HOSPITAL HAD 466 ADMISSIONS IN 2010 INCLUDING ADULT INPATIENT AND SWING BED ADMISSIONS. THERE WERE 2,104 EMERGENCY ROOM VISITS IN 2010, ALONG WITH 114,960 LABORATORY PROCEDURES, 9,296 THERAPY AND REHABILITATIVE SERVICES, 493 OUTPATIENT SURGERIES AND 10,775 IMAGING PROCEDURES PERFORMED. LMCV IS LICENSED FOR 25 ACUTE AND 31 LONG-TERM CARE BEDS, AND EMPLOYS OVER 320 STAFF MEMBERS. IN 2010, LMCV DISCHARGED MORE THAN 466 PATIENTS AND HAD MORE THAN 67,000 OUTPATIENT VISITS. NURSING HOME: EACH RESIDENT OF THE NURSING HOME RECEIVES PERSONALIZED MEDICAL, SOCIAL AND SPIRITUAL CARE. THE FOCUS IS ON PRESERVING THE LIFESTYLE OF EACH RESIDENT WITH 24-HOUR NURSING CARE, SOCIAL SERVICES, ACTIVITY THERAPY, DIETARY SERVICES, CHAPLAIN SERVICES, AND REHABILITATION THERAPY. THERE WERE 10,150 DAYS OF SERVICE IN THE NURSING HOME DURING 2010.CHARITY CARE: LMCV PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS/RESIDENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. CHARITY CARE IS AVAILABLE TO PATIENTS FINANCIALLY UNABLE TO PAY FOR SERVICES PROVIDED. THE COST OF CHARITY CARE PROVIDED IN 2010 WAS APPROXIMATELY $535,500. ADDITIONALLY, LMCV PROVIDES CARE BELOW COST TO PERSONS COVERED BY MEDICAID. THE UNREIMBURSED COST OF MEDICAID WAS APPROXIMATELY $796,600. THE COST OF OTHER MEANS TESTED GOVERNMENT PROGRAMS WAS APPROXIMATELY $61,100. LUTHER HOSPITAL AND MIDELFORT CLINIC (LUTHER MIDELFORT) VOLUNTARILY ENTERED INTO AN AGREEMENT WITH THE WI ATTORNEY GENERAL RELATING TO CHARITY CARE. THE TERMS OF THE AGREEMENT INCLUDE AN AUTOMATIC DISCOUNT FOR UNINSURED PATIENTS, A PAYMENT CAP FOR THOSE UNINSURED PATIENTS THAT MEET THE ORGANIZATION'S CHARITY CARE CRITERIA, AND A COMMITMENT TO MAKE INFORMATION AVAILABLE TO OUR PATIENTS REGARDING OUR CHARITY CARE PROGRAM. ADDITIONALLY, THE WI ATTORNEY GENERAL REVIEWED AND APPROVED OUR BILLING AND COLLECTION POLICIES AND PRACTICES. 4384534 9987 2368113 COMMUNITY BENEFIT/EDUCATION (SCHEDULE O)COMMUNITY BENEFIT: SUPPORT GROUPS: IN 2010, LMCV FACILITATED THREE SUPPORT GROUPS: DIABETIC (30 CONTACTS), CELIAC SPRUE (75 CONTACTS), AND BREAST CANCER (47 CONTACTS).COMMUNITY EDUCATION: LMCV COMMUNITY EDUCATION EFFORTS INCLUDE CLASSES IN BABYSITTING, SAFETY NET EDUCATION, AND VARIOUS DEPARTMENT PRESENTATIONS OPEN TO THE COMMUNITY AT NO COST. OUR PHYSICIANS HAVE PRESENTED TO GRADE SCHOOL CHILDREN THROUGHOUT THE YEAR ABOUT THE IMPORTANCE OF LIVING HEALTHY LIFESTYLES. WE HAVE INVOLVED A NUMBER OF DIFFERENT DISCIPLINES IN THE PROVISION OF THESE OFFERINGS. WE HAVE ESTABLISHED AN EVALUATION TOOL FOR THE PRESENTERS TO INDICATE WHAT ADDITIONAL SERVICES THAT OUR FACILITY CAN PROVIDE FOR THEM.SCHOOL CONTACTS. IN 2010, LMCV PROVIDED EDUCATION TO STUDENTS, KINDERGARTEN THROUGH HIGH SCHOOL ABOUT OUR FACILITY AND WHAT SERVICES WE PROVIDE. LMCV DONATES TO VARIOUS SCHOOL FUNCTIONS SUCH AS AFTER-PROM PARTIES AND MENTOR PROGRAMS AS WELL AS THE FIREPUP PROGRAMS IN THE CHIPPEWA VALLEY AND SPORTING FUNDRAISERS. COMMUNITY EVENTS: LMCV PARTICIPATES IN THE BLOOMER JUMP ROPE CONTEST IN JANUARY TO HELP ORGANIZE AND STAFF THE CONCESSION STAND DURING THIS EVENT. LMCV SET UP A BOOTH AND ARE SPONSORS OF THE COLFAX FAIR, THE BLOOMER FAIR AND THE NORTHERN WISCONSIN STATE FAIR. OUR FACILITY IS A CORPORATE SPONSOR FOR THE RELAY FOR LIFE WALK AND STAFF COORDINATE AND FUNDRAISE FOR THIS EVENT EACH YEAR RAISING APPROXIMATELY $3,000 IN ADDITION TO THE CORPORATE SPONSORSHIP AND PARTICIPATING IN THE RELAY FOR LIFE WALK. STAFF ALSO PARTICIPATED IN THE CHIPPEWA VALLEY HEART WALK AND THE MAKING STRIDES AGAINST BREAST CANCER WALKS, BOTH HELD IN EAU CLAIRE AND BOTH RAISING OVER $2,000 FOR THOSE CAUSES. IN COLLABORATION WITH THE AMERICAN RED CROSS FOR THE FIFTH YEAR, LUTHER MIDELFORT CHIPPEWA VALLEY AND CUMMINS FILTRATION SPONSORED THE SUMMER BLOOMER BLOOD DRIVE FOR THE SURROUNDING COMMUNITY. OUR FACILITY BUS AND STAFF MEMBERS PARTICIPATED IN PARADES IN BLOOMER, CHIPPEWA FALLS AND COLFAX DURING THE SUMMER MONTHS. A SAFETY CAMP WAS HELD IN CHIPPEWA FALLS FOR 4TH AND 5TH GRADERS TO PROMOTE HEALTH AND SAFETY TO THE 49 CHILDREN IN ATTENDANCE. IN OCTOBER, A HEALTH FAIR WAS HELD IN BLOOMER IN CONJUNCTION WITH THE COMMUNITY WOMEN'S CLUB ARTS AND CRAFTS FAIR FOR THE FIFTH YEAR WITH ATTENDANCE BEING AROUND 350 PEOPLE. A FALL WOMEN'S HEALTH FAIR WAS ALSO HELD AT THE CLINIC IN COLFAX AND ABOUT 60 PEOPLE ATTENDED. VARIOUS BOOTHS, INFORMATION AND SCREENINGS ARE CONDUCTED THROUGHOUT THE YEAR WITHIN THE SURROUNDING COMMUNITY AS WELL.OUR CLINICS ALSO HOST ELEMENTARY STUDENTS FOR KIDS' CLINIC DAYS IN BLOOMER, CHIPPEWA FALLS AND COLFAX. GROWING UP CLASSES WERE HELD FOR GIRLS AND BOYS ENTERING PUBERTY IN CHIPPEWA FALLS IN THE SPRING AND FALL. IN 2010, THE FACILITY WAS ALSO AN ACTIVE PARTICIPANT IN: LOVE LIGHT TREE FUNDRAISER, CHAMBER OF COMMERCE EVENTS AND AREA FOOD PANTRIES. FIVE FAMILIES WERE SPONSORED AND PROVIDED WITH CHRISTMAS GIFTS DURING THE HOLIDAYS. FIVE $500 SCHOLARSHIPS WERE AWARDED TO GRADUATING STUDENTS PURSUING A HEALTH RELATED CAREER.IN 2010, MEDICAL SUPPLIES WERE DONATED TO THE CHIPPEWA VALLEY FREE CLINIC LOCATED IN CHIPPEWA FALLS. VOLUNTEER PROGRAM (SCHEDULE O)VOLUNTEER PROGRAM: LMCV HAS A VOLUNTEER PROGRAM COMPRISED OF APPROXIMATELY 47 COMMUNITY MEMBERS. COMMUNITY VOLUNTEERS ASSIST ACTIVITY, HEALTH INFORMATION, SOCIAL SERVICES, HOSPITAL NURSING, AND ADMINISTRATION DEPARTMENTS. THE VOLUNTEERS ASSIST BY HELPING PLANT FLOWERS, GREET PATIENTS, AND ASSIST RESIDENTS DURING ACTIVITY PROGRAMMING. THE VOLUNTEERS ARE VERY INSTRUMENTAL IN HELPING WITH FUND RAISING EVENTS FOR THE MEDICAL CENTER. ABOUT 2,347 HOURS WERE DONATED IN 2010 AT AN APPROXIMATE VALUE OF $50,100 - BASED ON STATISTICS FROM THE INDEPENDENT SECTOR. 27410841 1 1 0 0 0 0 0 1 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 369 1 0 0 0 0 0 0 0 0 0 0 X 11 5 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 0 0 WI X CORPORATE TAX UNIT 5075381297 200 FIRST STREET SW ROCHESTER MN 55905 X BERGERON-BOWE MELISSA 1.00 X 0 0 0 BLAIR MD DAVID 1.00 X 0 206084 49836 BYRD MD JANE 1.00 X 0 218693 52864 GEISSLER DENNIS 1.00 X X 0 0 0 GLADITSCH MD RICHARD 1.00 X 0 217798 50788 IRWIN DDS DAVE 1.00 X 0 0 0 KUEHL MD MARY 1.00 X 0 115212 39620 LARSON MD JOHN L 1.00 X X 0 391684 49204 OLSON SHELLY 1.00 X X 0 0 0 RYAN MICHAEL 1.00 X X 0 115763 30303 STIEHL DAVID 1.00 X 0 0 0 LINTON MD RANDALL L 1.00 X 0 516417 58816 WITTROCK EDWARD A 40.00 X 0 186054 45891 ARMSTRONG JAMES L 40.00 X 119873 0 34456 JONES JILL 40.00 X 114170 0 11991 KLUND STEVEN 40.00 X 141171 0 14215 REIMER ROBERT S 40.00 X 133042 0 21794 REIMER RONALD J 40.00 X 239887 0 53299 SKOLD COLLEEN 1.00 X 0 161337 35703 748143 2129042 548780 5 1 1 0 MAYO FOUNDATION FOR MEDICAL EDUCATION AN 200 FIRST STREET SW ROCHESTER MN 55905 PURCHASING AGENT 4117207 LUTHER HOSPITAL 1221 WHIPPLE STREET EAU CLAIRE WI 54703 PURCHASED SERVICES 1253037 MIDELFORT CLINIC LTD -- MAYO HEALTH SY PO BOX 1510 EAU CLAIRE WI 54702 PURCHASED SERVICES 1029879 MAYO COLLABORATIVE SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 PURCHASED SERVICES 121027 4 13961 36570 45361 6322 95892 NET PATIENT REVENUE 620000 31011504 31011504 SHARED SERVICES REVENU 561000 28168 28168 RENTAL REVENUE FROM AF 531120 13769 13769 EDUCATION REVENUE 611600 149 149 31053590 99083 99083 1714 1714 1714 1714 53338 -53338 -53338 -53338 10468 13961 5083 5385 5385 2600 755 1845 1845 CAFETERIA/VENDING REVE 722210 47341 47341 MEDICAL RECORD/TRANSCR 541900 18408 18408 MEDICAL DIRECTOR FEES 541900 7200 7200 330 330 73279 31277450 31119669 0 61889 7987 7987 2000 2000 15825719 14646283 1179436 1162781 1076123 86658 1438553 1331343 107210 1049849 971607 78242 58607 58557 50 3535 3535 16039 1942 14097 4034196 3922556 111165 475 39499 13351 26062 86 2755924 2726521 29334 69 129399 97972 31427 591543 503038 88505 189869 173815 15585 469 14479 14435 44 54 54 624291 603584 18827 1880 157120 157120 BAD DEBT EXPENSE 948392 947952 440 MEDICAID SURCHARGE 118889 118889 DUES, LICENSES AND SUBS 31333 28046 3287 EMPLOYEE RELATED EXPENS 11815 7720 4095 OTHER TAXES 115 115 29211988 27410841 1794023 7124 15008 36909 40258 66657 4209064 4260932 20000 9805 9352 79493 82950 15250115 7081342 7248315 8168773 7515175 9323288 737576 371783 19854694 22340644 3502223 3508647 559 1631860 1960125 5134642 5468772 X 14678496 16859752 41556 12120 14720052 16871872 19854694 22340644 X 2065462 86358 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 103 5133 4788 448 0 263695 263695 9288711 4435392 4853319 2955410 2115195 840215 2742299 530755 2211544 8168773 MAYO CLINIC INVESTMENT POOL 9323288 F 9323288 DUE TO AFFILIATES 1960125 1960125 Part IV, Line 1b: NURSING HOME RESIDENT FUNDS Description of Uncertain Tax Positions Under FIN 48: Part X: AT DECEMBER 31, 2010 AND 2009, THERE WAS NO MATERIAL LIABILITY FOR UNRECOGNIZED TAX BENEFITS FOR THE FILING ORGANIZATION. GOLF OUTING 7393 4255 3138 788 825 DANCING WITH THE COMMUNITY 12445 5115 7330 300 2125 1045 4 4591 4591 24429 13961 10468 1088 2950 1045 5083 5385 1 1 1 X 1 X 1 1 1 0 1 1 535536 535536 0.01890 2479940 1683308 796632 0.02820 1389593 1328495 61098 0.00220 4405069 3011803 1393266 0.04930 23723 23723 0.00080 14000 14000 0.00050 4330280 2367438 1962842 0.06940 7987 7987 0.00030 4375990 2367438 2008552 0.07100 8781059 5379241 3401818 0.12030 3825 5588 5588 0.00020 362 2532 2532 0.00010 135 424 424 0.00000 4322 8544 8544 0.00030 0 566776 6893909 6813683 80226 X 1 1 1 1 BLOOMER MEMORIAL MEDICAL CENTER -- MAYO

1501 THOMPSON STREET BLOOMER WI 54724

X X X X NOT REQUIRED 1 4 BLOOMER CLINIC

1501 THOMPSON STREET BLOOMER WI 54724

CLINIC CHIPPEWA FALLS CLINIC

611 1ST AVE CHIPPEWA FALLS WI 54729

CLINIC THE MAPLEWOOD

1501 THOMPSON STREET BLOOMER WI 54724

NURSING HOME COLFAX CLINIC

1010 HIGH STREET COLFAX WI 54730

CLINIC Part I, Line 6a: THE ANNUAL REPORT FOR THE FILING ORGANIZATION IS PART OF A CONSOLIDATED REPORT PREPARED BY MAYO 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 7g: THE FOLLOWING NET COMMUNITY BENEFIT COST ATTRIBUTED TO A PHYSICIAN CLINIC WAS INCLUDED AS SUBSIDIZED HEALTH SERVICES: $98,074 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 $ 948391. Part II: LMCV IS AN ACTIVE PARTICIPANT IN ITS COMMUNITY. IN 2010 THE ORGANIZATION SUPPORTED THE FOLLOWING PROGRAMS: ECONOMIC DEVELOPMENT COUNCIL, CHAMBER OF COMMERCE, DISASTER READINESS, FOOD PANTRY, WORKFORCE DEVELOPMENT/HEALTHCARE TALKS. LMCV'S PARTICIPATION IS PROMOTING GOOD HEALTH IN THE COMMUNITIES IT SERVES. Part III, Line 4: BAD DEBT EXPENSE AT COST IS DETERMINED USING THE SAME COST-TO-CHARGE RATIO THAT IS USED TO CALCULATE FINANCIAL ASSISTANCE AND MEDICAID SHORTFALL. DISCOUNTS AND ALLOWANCES ARE ACCOUNTED FOR SEPARATELY FROM BAD DEBT EXPENSE.FROM CONSOLIDATED FINANCIAL STATEMENTS: ACCOUNTS RECEIVABLE FOR MEDICAL SERVICES - ACCOUNTS RECEIVABLE FOR MEDICAL SERVICES ARE STATED AT NET REALIZABLE VALUE. THE CLINIC ESTIMATES THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED ON HISTORIC WRITE-OFFS AND THE AGING OF THE ACCOUNTS. ACCOUNTS ARE WRITTEN OFF WHEN COLLECTION EFFORTS HAVE BEEN EXHAUSTED.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. Part III, Line 8: THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. 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 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 8 AND PART VI MEDICARE SHORTFALL: THE MEDICARE COST REPORT DATA PROVIDED IS FROM A SHORT PERIOD MEDICARE COST REPORT. DURING 2010, THE REPORTING ENTITY CHANGED TO A 9/30 FISCAL YEAR END FOR MEDICARE COST REPORTING. 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 EVERY REASONABLE ATTEMPT TO COLLECT FROM INSURANCE COMPANIES AND OTHER THIRD-PARTY PAYORS. 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 MEETING MAYO CLINIC'S FINANCIAL ASSISTANCE ELIGIBILTY CRITERIA OR THE PATIENT ASKS TO APPLY FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY IS SUSPENDED UNTIL MAYO REVIEWS THE ACCOUNT FOR FINANCIAL ASSISTANCE ELIGIBILITY. COLLECTION ACTIVITY WOULD ONLY RESUME IF MAYO WOULD TELL THE COLLECTION AGENCY TO PURSUE COLLECTIONS ON THE BALANCE OR PARTIAL BALANCE IF THERE WAS A CHARITY ADJUSTMENT. 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 THE WISCONSIN HOSPITAL ASSOCIATION. Part VI, Line 2: ADMINISTRATION, ALONG WITH MEMBERS OF THE LUTHER MIDELFORT FOUNDATION, WORK CLOSELY WITH LOCAL EDUCATIONAL INSTITUTIONS, AREA FREE CLINICS, NEIGHBORHOOD ASSOCIATIONS, CHARITIES, AND HEALTH DEPARTMENTS TO ASSESS HEALTHCARE NEED. MONETARY DONATIONS, SERVICES, EDUCATION, VOLUNTEERS AND GOODS ARE SUPPLIED ONCE THOSE NEEDS ARE ASSESSED. REQUESTS FOR ASSISTANCE ARE TRIAGED THROUGH THE CORPORATE COMMUNICATION DEPARTMENTS, AND EVALUATED BASED ON ANNUAL STRATEGY. PART OF THAT STRATEGY INCLUDES INPUT FROM THE RESPONSIBLE VICE PRESIDENT AND ULTIMATELY REVIEWED BY THE LMCV ACCORDING TO THE DONATION REQUEST FLOWCHART. THE LMF ANNUAL STRATEGY IS BASED ON COMMUNITY HEALTH NEED, STRATEGIC INITIATIVES AND COMMUNITY ASSESSMENTS. Part VI, Line 3: ELIGIBILITY: THE CHARITY CARE INFORMATION BROCHURE IS PROMINENTLY DISPLAYED IN REGISTRATION AND PATIENT-ACCOUNT WAITING AREAS. THE BROCHURE EXPLAINS THE CHARITY CARE PROGRAM AND FACTORS AFFECTING ELIGIBILITY. IDENTIFICATION: THERE ARE A NUMBER OF WAYS A PATIENT CAN BE IDENTIFIED AND EVALUATED FOR CHARITY CARE ASSISTANCE.1. PATIENTS MAY REQUEST FINANCIAL ASSISTANCE.2. MAYO CLINIC EMPLOYEES MAY REFER PATIENTS TO A FINANCIAL COUNSELOR.3. COLLECTION AGENCIES MAY REFER PATIENTS.4. THE BUSINESS SERVICES/PATIENT FINANCIAL SERVICES DEPARTMENT MAY REFER PATIENTS TO A FINANCIAL COUNSELOR.5. REFERRING PHYSICIANS MAY REFER PATIENTS.6. MAYO PHYSICIANS MAY REFER PATIENTS.7. LOCAL GOVERNMENT AGENCIES MAY REFER PATIENTS.INDIGENT CARE: EMERGENCY ROOM PATIENTS WHO CANNOT PAY THEIR BILLS MAY BE CLASSIFIED AS "CHARITY" IF THEY DO NOT HAVE A JOB, MAILING ADDRESS, RESIDENCE, OR INSURANCE. CONSIDERATION MUST ALSO BE GIVEN TO CLASSIFYING EMERGENCY ROOM ONLY PATIENTS AS CHARITY IF THEY DO NOT PROVIDE ADEQUATE INFORMATION AS TO THEIR FINANCIAL STATUS. IN MANY INSTANCES, THESE PATIENTS ARE HOMELESS AND HAVE FEW RESOURCES TO COVER THE COST OF THEIR CARE.GOVERNMENTAL ASSISTANCE: IN DETERMINING WHETHER AN INDIVIDUAL QUALIFIES FOR CHARITY CARE, OTHER COUNTY OR GOVERNMENTAL ASSISTANCE PROGRAMS SHOULD ALSO BE CONSIDERED. MANY APPLICANTS ARE NOT AWARE THAT THEY MAY BE ELIGIBLE FOR PUBLIC HEALTH INSURANCE PROGRAMS.1. MAYO CLINIC STAFF WILL HELP THE INDIVIDUAL DETERMINE ELIGIBILITY FOR GOVERNMENTAL OR OTHER ASSISTANCE, AS APPROPRIATE.2. PERSONS WHO ARE ELIGIBLE FOR PROGRAMS (SUCH AS STATE-SPONSORED MEDICAID) BUT WHO WERE NOT COVERED AT THE TIME THAT MEDICAL SERVICES WERE GRANTED MAY BE GRANTED CHARITY CARE, PROVIDED THAT THE PATIENT NOW APPLIES FOR GOVERNMENT ASSISTANCE. THIS MAY BE PRUDENT, ESPECIALLY IF THE PATIENT REQUIRES ONGOING SERVICES. Part VI, Line 4: LUTHER MIDELFORT CHIPPEWA VALLEY (LMCV) IS LOCATED IN BLOOMER, WISCONSIN. ITS SERVICE AREA INCLUDES CHIPPEWA COUNTY AND A PORTION OF DUNN, COUNTY IN NORTHWESTERN WISCONSIN. LMCV IS A DESIGNATED CRITICAL ACCESS HOSPITAL FOR MEDICARE PURPOSES AND IS ONE OF TWO HOSPITALS IN CHIPPEWA COUNTY. THE POPULATION OF CHIPPEWA COUNTY (WHICH COMPRISES THE MAJORITY OF LMCV'S SERVICE AREA) IS APPROXIMATELY 61,828. ACCORDING TO 2008 CENSUS DATA, APPROXIMATELY 10.9% OF CHIPPEWA COUNTY INDIVIDUALS ARE LIVING BELOW POVERTY LEVEL. IN ADDITION, ACCORDING TO THE 2005-2007 WISCONSIN FAMILY HEALTH SURVEY, APPROXIMATELY 6% OF THE CHIPPEWA COUNTY POPULATION WAS UNINSURED FOR ALL OR PART OF THE PAST YEAR. ACCORDING TO COUNTY HEALTH RANKINGS "SNAPSHOT: 2010", CHIPPEWA COUNTY RANKED 32 OF 72 COUNTIES IN HEALTH OUTCOMES AND 30 OF 72 IN HEALTH FACTORS. CHIPPEWA COUNTY SERVICE AREA IS A MEDICALLY UNDERSERVED AREA AS DESIGNATED BY HRSA. Part VI, Line 6: THIS HOSPITAL IS AN AFFILIATE OF THE 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 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. 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 CLINICS 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 - 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 7: 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. 1 X 0 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: THE FILING ORGANIZATION CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY WITH PROGRAMS THAT ENHANCE THE MISSION OF THE FILING ORGANIZATION. THE FILING ORGANIZATION ONLY CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY THAT ADDRESS UNMET OR UNDER-FUNDED COMMUNITY NEEDS IN THE AREAS OF HEALTHCARE, EDUCATION, RESEARCH, DIVERSITY AND EQUALITY OF OPPORTUNITY. NO ADDITIONAL MONITORING IS PERFORMED. TRANSFERS OR GRANTS TO TAX-EXEMPT ORGANIZATIONS WILL BE USED PURSUANT TO THE POLICIES AND PROCEDURES OF THE GRANTEE ORGANIZATIONS AND TO FURTHER THE EXEMPT PURPOSES OF THE GRANTEE ORGANIZATIONS. BOTH THE FILING ORGANIZATION AND THE GRANTEE ORGANIZATION MAINTAIN ADEQUATE BOOKS AND RECORDS OF SUCH TRANSFERS OR GRANTS. NO ADDITIONAL MONITORING IS PERFORMED. 0 0 0 0 0 0 0 0 0 BLAIR MD DAVID 0 185268 0 4240 0 16576 0 21143 0 28693 0 255920 0 0 BYRD MD JANE 0 202292 0 5857 0 10544 0 22497 0 30367 0 271557 0 0 GLADITSCH MD RICHARD 0 205278 0 4785 0 7735 0 22193 0 28595 0 268586 0 0 KUEHL MD MARY 0 106605 0 2499 0 6108 0 11529 0 28091 0 154832 0 0 LARSON MD JOHN L 0 184896 0 12930 0 193858 0 25170 0 24034 0 440888 0 0 LINTON MD RANDALL L 0 461263 0 52400 0 2754 0 25170 0 33646 0 575233 0 0 WITTROCK EDWARD A 0 171312 0 12192 0 2550 0 25148 0 20743 0 231945 0 0 ARMSTRONG JAMES L 116527 0 3346 0 0 0 11704 0 22752 0 154329 0 0 0 KLUND STEVEN 140806 0 0 0 365 0 13957 0 258 0 155386 0 0 0 REIMER ROBERT S 129111 0 3881 0 50 0 13151 0 8643 0 154836 0 0 0 REIMER RONALD J 236110 0 3777 0 0 0 25170 0 28129 0 293186 0 0 0 SKOLD COLLEEN 0 159049 0 0 0 2288 0 16022 0 19681 0 197040 0 0 Supplemental Information Part III COMPENSATION PAID TO BOARD MEMBERS IS PRIMARILY FOR PROFESSIONAL RESPONSIBILITIES AS PHYSICIANS, ADMINISTRATORS, OR EMPLOYEES OF THE ORGANIZATION. 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. Form 990, Part VI, Section A, line 2 EDWARD WITTROCK AND RANDALL L. LINTON, M.D. ARE BOTH OFFICERS OF NORTHWEST HEALTH VENTURES, INC. DUE TO OVERLAP OF BOARD MEMBERSHIP AND EMPLOYMENT ON RELATED EXEMPT ENTITIES, THE FOLLOWING INDIVIDUAL: RANDALL L. LINTON, M.D. HAS A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS: DAVID BLAIR, M.D. JANE D. BYRD M.D. RICHARD GLADITSCH M.D. MARY KUEHL M.D. JOHN L. LARSON M.D. MICHAEL RYAN COLLEEN SKOLD EDWARD A. WITTROCK Form 990, Part VI, Section A, line 3 MAYO-AFFILIATED ENTITIES ROUTINELY DELEGATED VARIOUS MANAGEMENT AND SUPPORT FUNCTIONS TO RELATED ENTITIES. Form 990, Part VI, Section A, line 6 THE SOLE CORPORATE MEMBER IS LUTHER HOSPITAL Form 990, Part VI, Section A, line 7a THE GOVERNING BODY IS ELECTED BY THE SOLE CORPORATE MEMBER. Form 990, Part VI, Section A, line 7b THE ARTICLES AND BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, AND DEBT, AMENDMENT OF THE ARTICLES AND BYLAWS, AND GENERAL OPERATION DECISIONS. Form 990, Part VI, Section A, line 8b THERE ARE NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE BOARD. HENCE, 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 ASSISTANT ADMINISTRATOR OF FINANCE, THE REGIONAL SITE VICE PRESIDENT, AND 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. HIGHLIGHTS ARE PRESENTED TO BOARD MEMBERS, AND THE REVIEW IS DOCUMENTED IN MEETING MINUTES. ALL QUESTIONS ARE ADDRESSED PRIOR TO FILING THE FORM 990. Form 990, Part VI, Section B, line 12c THE FILING ORGANIZATION IS AN AFFILIATE OF MAYO CLINIC. 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 THE 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 AND ADMINISTRATIVE LEADERSHIP. IN ADDITION TO ANY REVIEW AND APPROVAL THAT MAY TAKE PLACE AT THE LOCAL ENTITY LEVEL, THE FOLLOWING INDEPENDENT APPROVAL PROCESS OCCURS ANNUALLY. THE SALARY OF THE CEO, PRESIDENT AND SEVERAL BOARD MEMBERS WERE REVIEWED BY THE MAYO HEALTH SYSTEM COMPENSATION AND BENEFITS COMMITTEE PURSUANT TO THE PROCESS DESCRIBED BELOW FOR MAYO HEALTH SYSTEM PHYSICIANS. THE MAYO HEALTH SYSTEM COMPENSATION AND BENEFITS COMMITTEE INITIALLY REVIEWS THE COMPENSATION OF PHYSICIANS AND ADMINISTRATIVE LEADERSHIP FOR THE MAYO HEALTH SYSTEM ENTITIES. THE COMMITTEE IS COMPRISED OF MAYO EMPLOYEES, BUT IS INDEPENDENT FOR INTERNAL REVENUE CODE 4958 FOR THE INDIVIDUALS WHOSE SALARY IS REVIEWED (WITH RECUSAL WHERE APPROPRIATE). FOR THOSE INDIVIDUALS FOR WHICH THIS COMMITTEE CAN NOT SERVE AS THE INDEPENDENT REVIEW, THEIR COMPENSATION AND BENEFITS ARE REVIEWED BY THE GOVERNANCE COMMITTEE (DESCRIBED BELOW). THE COMPENSATION AND BENEFITS COMMITTEE USES COMPARABILITY DATA (INCLUDING THIRD-PARTY BENCHMARKING SURVEYS) IN ITS REVIEW AND DOCUMENTS DECISIONS IN ITS MINUTES. INFORMATION ON MAYO HEALTH SYSTEM PHYSICIAN AND ADMINISTRATIVE LEADERSHIP COMPENSATION AND BENEFITS IS ALSO REVIEWED BY THE MAYO CLINIC COMMITTEE ON OFFICER SUCCESSION, COMPENSATION AND GOVERNANCE (GOVERNANCE COMMITTEE), WHICH IS COMPRISED OF SEVEN OF THE EXTERNAL INDEPENDENT MEMBERS OF THE MAYO CLINIC BOARD OF TRUSTEES. Form 990, Part VI, Section C, line 19 GOVERNING DOCUMENTS NOT PUBLICLY AVAILABLE. CONFLICT OF INTEREST POLICY AVAILABLE UPON REQUEST AND ALSO ON MAYOCLINIC.ORG WEBSITE. FINANCIAL STATEMENTS ARE ATTACHED TO FORM 990. AVERAGE HOURS PER WEEK DEVOTED TO POSITION WITH RELATED ORGANIZATION PART VII SECTION A BLAIR M.D., DAVID 40 HOURS BYRD M.D., JANE D. 40 HOURS GLADITSCH M.D., RICHARD 40 HOURS KUEHL M.D., MARY 40 HOURS LARSON M.D., JOHN L. 40 HOURS LINTON M.D., RANDALL L. 40 HOURS RYAN, MICHAEL 40 HOURS SKOLD, COLLEEN M. 40 HOURS WITTROCK, EDWARD A. 40 HOURS Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 86,358. PART XII LINE 2C EXPLANATION THERE WAS NO CHANGE IN THE PROCESS DURING THE YEAR. ALBERT LEA MEDICAL CENTER -- MAYO HEALTH SYSTEM 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 411404075 HOSPITAL AND CLINIC MN 501(c)(3) 3 MAYO CLINIC 1 AUSTIN MEDICAL CENTER -- MAYO HEALTH SYSTEM 1000 FIRST DRIVE NW AUSTIN MN 55912 410695606 HOSPITAL AND CLINIC MN 501(c)(3) 3 MAYO CLINIC 1 AUSTIN MEDICAL CENTER FOUNDATION 1000 FIRST DRIVE NW AUSTIN MN 55912 300107471 FUNDRAISING FOUNDATION MN 501(c)(3) 7 AUSTIN MEDICAL CENTER -- MAYO HEALTH SYSTEM 1 BARRON MEMORIAL MEDICAL CENTER -- MAYO HEALTH SYSTEM 1222 EAST WOODLAND AVE BARRON WI 54812 390920634 HOSPITAL AND CLINIC WI 501(c)(3) 3 LUTHER HOSPITAL 1 BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(c)(3) 7 BLOOMER MEMORIAL MEDICAL CENTER INC -- MAYO HEALTH SYSTEM 1 BLOOMER MEMORIAL MEDICAL CENTER INC -- MAYO HEALTH SYSTEM 1501 THOMPSON STREET BLOOMER WI 54724 390980343 HOSPITAL AND CLINIC WI 501(c)(3) 3 LUTHER HOSPITAL 1 CANNON FALLS MEDICAL CENTER -- MAYO HEALTH SYSTEM 1116 WEST MILL STREET CANNON FALLS MN 55009 204156428 HOSPITAL AND CLINIC MN 501(c)(3) 3 MAYO CLINIC 1 CHARTERHOUSE INC 200 FIRST STREET SW ROCHESTER MN 55905 411405254 RETIREMENT LIVING CENTER MN 501(c)(3) 9 MAYO CLINIC 1 FAIRMONT MEDICAL CENTER -- MAYO HEALTH SYSTEM 800 MEDICAL CENTER DRIVE PO BOX 800 FAIRMONT MN 56031 410760836 HOSPITAL AND CLINIC MN 501(c)(3) 3 MAYO CLINIC 1 FOUNTAIN LAKE TREATMENT CENTER 404 WEST FOUNTAIN STREET ALBERT LEA MN 56007 411404076 CHEMICAL DEPENDENCY TREATMENT MN 501(c)(3) 3 ALBERT LEA MEDICAL CENTER -- MAYO HEALTH SYSTEM 1 FRANCISCAN SKEMP FOUNDATION OF ARCADIA INC 464 SOUTH JOHNSON STREET ARCADIA WI 54612 391322480 FUNDRAISING FOUNDATION WI 501(c)(3) 9 FRANCISCAN SKEMP HEALTHCARE INC 1 FRANCISCAN SKEMP FOUNDATION OF SPARTA INC 310 WEST MAIN STREET SPARTA WI 54656 391423234 FUNDRAISING FOUNDATION WI 501(c)(3) 9 FRANCISCAN SKEMP HEALTHCARE INC 1 FRANCISCAN SKEMP FOUNDATION INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391186647 FUNDRAISING FOUNDATION WI 501(c)(3) 11-II FRANCISCAN SKEMP HEALTHCARE INC 1 FRANCISCAN SKEMP HEALTHCARE INC 700 WEST AVE SOUTH LA CROSSE WI 54601 391411999 HEALTHCARE SYSTEM PARENT WI 501(c)(3) 11-I MAYO CLINIC 1 FRANCISCAN SKEMP MEDICAL CENTER INC 700 WEST AVE SOUTH LA CROSSE WI 54601 390806374 HOSPITAL AND CLINIC WI 501(c)(3) 3 FRANCISCAN SKEMP HEALTHCARE INC 1 GCAS 200 FIRST STREET SW ROCHESTER MN 55905 411917517 AMBULANCE SERVICE MN 501(c)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(c)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 GOLD CROSS AMBULANCE INC 200 FIRST STREET SW ROCHESTER MN 55905 391942957 AMBULANCE SERVICE MN 501(c)(3) 9 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 IMMANUEL-ST JOSEPH'S -- MAYO HEALTH SYSTEM 1025 MARSH STREET MANKATO MN 56002 411236756 HOSPITAL AND CLINIC MN 501(c)(3) 3 MAYO CLINIC 1 IMMANUEL-ST JOSEPH'S FOUNDATION -- MAYO HEALTH SYSTEM 1025 MARSH STREET MANKATO MN 56002 411663357 FUNDRAISING FOUNDATION MN 501(c)(3) 7 IMMANUEL-ST JOSEPH'S -- MAYO HEALTH SYSTEM 1 LAKE CITY MEDICAL CENTER - MAYO HEALTH SYSTEM 500 WEST GRANT STREET LAKE CITY MN 55041 411906820 HOSPITAL MN 501(c)(3) 3 MAYO CLINIC 1 LUTHER HOSPITAL 1221 WHIPPLE STREET EAU CLAIRE WI 54703 390813418 HOSPITAL WI 501(c)(3) 3 MAYO CLINIC 1 LUTHER LAKESIDE APARTMENTS INC 714 SOUTH BARSTOW STREET EAU CLAIRE WI 54701 391409024 LOW INCOME HOUSING WI 501(c)(3) 9 LUTHER HOSPITAL 1 LUTHER MIDELFORT FOUNDATION INC 733 W CLAIREMONT AVE PO BOX 1510 EAU CLAIRE WI 54702 391633407 GRANTMAKING FOUNDATION WI 501(c)(3) PF MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM 0 MAYO CLINIC ARIZONA 13400 EAST SHEA BLVD 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 JACKSONVILLE 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 593337028 PATIENT CARE - CLINIC FL 501(c)(3) 7 MAYO CLINIC 1 MAYO CLINIC -- METHODIST HOSPITAL 200 FIRST STREET SW ROCHESTER MN 55905 410739106 HOSPITAL MN 501(c)(3) 3 MAYO CLINIC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - CLINIC MN 501(c)(3) 9 MAYO CLINIC 1 MAYO CLINIC -- SAINT MARYS HOSPITAL 200 FIRST STREET SW ROCHESTER MN 55905 410944601 HOSPITAL MN 501(c)(3) 3 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 MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM PO BOX 1510 EAU CLAIRE WI 54702 391735831 PATIENT CARE - CLINIC WI 501(c)(3) 3 MAYO CLINIC 0 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 NORTHWEST WISCONSIN HOMECARE INC PO BOX 2060 EAU CLAIRE WI 54702 391491516 HOME HEALTH AND HOSPICE CARE WI 501(c)(3) 9 LUTHER HOSPITAL 1 NORTHWEST WISCONSIN SUPPORTIVE HOMECARE INC PO BOX 2060 EAU CLAIRE WI 54702 391686673 HOME HEALTH CARE WI 501(c)(3) 9 LUTHER HOSPITAL 1 OSSEO MEDICAL CENTER INC -- MAYO HEALTH SYSTEM PO BOX 70 / 13025 EIGHTH STREET OSSEO WI 54758 391029430 HOSPITAL AND CLINIC WI 501(c)(3) 3 LUTHER HOSPITAL 1 POVERELLO FOUNDATION 200 FIRST STREET SW ROCHESTER MN 55905 411494881 FUNDRAISING FOUNDATION MN 501(c)(3) 11-I MAYO CLINIC -- SAINT MARYS HOSPITAL 1 RED CEDAR MEDICAL CENTER INC -- MAYO HEALTH SYSTEM 2321 STOUT ROAD MENOMONIE WI 54751 510190875 HOSPITAL AND CLINIC WI 501(c)(3) 3 MAYO CLINIC 1 SPRINGFIELD MEDICAL CENTER -- MAYO HEALTH SYSTEM 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(c)(3) 3 IMMANUEL-ST JOSEPH'S -- MAYO HEALTH SYSTEM 1 ST JAMES MEDICAL CENTER -- MAYO HEALTH SYSTEM 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 410797368 HOSPITAL AND CLINIC MN 501(c)(3) 3 IMMANUEL-ST JOSEPH'S -- MAYO HEALTH SYSTEM 1 ST JAMES MEDICAL CENTER FOUNDATION INC 1101 MOULTON PARSONS DR PO BOX 460 ST JAMES MN 56081 411444129 FUNDRAISING FOUNDATION MN 501(c)(3) 7 ST JAMES MEDICAL CENTER -- MAYO HEALTH SYSTEM 1 WASECA MEDICAL CENTER -- MAYO HEALTH SYSTEM 501 NORTH STATE STREET WASECA MN 56093 363606405 HOSPITAL AND CLINIC MN 501(c)(3) 3 IMMANUEL-ST JOSEPH'S -- MAYO HEALTH SYSTEM 1 MAYO KLINIK STIFTUNG 60486 FRANKFURT AM MAIN FRANKFURT GM FUNDRAISING FOUNDATION GM MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH 1 FRANKLIN HEATING STATION 119 THIRD ST SW ROCHESTER MN 55902 410264830 UTILITY MN N/A CANNON VALLEY CLINIC -- MAYO HEALTH SYSTEM 635 FIRST STREET SE FARIBAULT MN 55021 411817179 PATIENT CARE - CLINIC MN N/A C DECORAH CLINIC -- MAYO HEALTH SYSTEM 907 MONTGOMERY STREET DECORAH IA 52101 411711329 PATIENT CARE - CLINIC IA N/A C FIOS THERAPEUTICS INC 200 FIRST STREET SW ROCHESTER MN 55905 711029189 RESEARCH MN N/A C HEALTH TRADITION HEALTH PLAN 1808 EAST MAIN STREET ONALASKA WI 54650 391545987 MEDICAL SERVICES COMPANY WI N/A C LOBSS NETWORK SUPPORT 2002 INC 200 FIRST STREET SW ROCHESTER MN 55905 481276150 ADMINISTRATIVE SERVICES MN N/A C MAYO COLLABORATIVE SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 411346366 REFERENCE LAB SERVICES MN N/A C MAYO HOLDING COMPANY 200 FIRST STREET SW ROCHESTER MN 55905 411578020 HOLDING COMPANY MN N/A C MAYO INSURANCE COMPANY LTD 200 FIRST STREET SW ROCHESTER MN 55905 SELF INSURANCE POOL CJ N/A C MAYO MEDICAL LABORATORIES NEW ENGLAND INC 265 BALLARDVALE STREET WILMINGTON MA 01887 043323713 LABORATORY SERVICES MA N/A C MAYO REGIONAL PRACTICES OF ARIZONA 13400 EAST SHEA BOULEVARD SCOTTSDALE AZ 85259 061190278 THIRD PARTY ADMINISTRATION SERVICES AZ N/A C MHS SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 411282517 EQUIPMENT & REAL ESTATE LEASING MN N/A C MMSI INC 21 FIRST STREET SW ROCHESTER MN 55905 411547003 THIRD PARTY ADMINISTRATION SERVICES MN N/A C NORTHWEST HEALTH VENTURES INC 1221 WHIPPLE STREET EAU CLAIRE WI 54703 391528920 PHARMACY SERVICES WI N/A C OWATONNA CLINIC -- MAYO HEALTH SYSTEM 134 SOUTHVIEW OWATONNA MN 55060 411862132 PATIENT CARE - CLINIC MN N/A C PHYSICIAN AND HOSPITAL PRACTICES INC 4500 SAN PABLO ROAD JACKSONVILLE FL 32224 930926631 HEALTH SERVICES FL N/A C ROCHESTER AIRPORT COMPANY ROUTE 2 ROCHESTER MN 55902 410506870 AIRPORT MANAGEMENT MN N/A C SUPERBLOCK 3 PROPERTY OWNERS ASSOCIATION 13400 E SHEA BLVD SCOTTSDALE AZ 85259 860870505 COMMERCIAL PROPERTY OWNERS ASSOCIATION AZ N/A C THE STABILE BUILDING OWNERS' ASSOCIATION 200 FIRST STREET SW ROCHESTER MN 55905 208994499 COMMERCIAL PROPERTY OWNERS ASSOCIATION MN N/A C 1 0 1 0 0 0 1 0 0 0 1 1 0 1 1 0 1 1 BARRON MEMORIAL MEDICAL CENTER -- MAYO HEALTH SYSTEM N 154078 GAAP BARRON MEMORIAL MEDICAL CENTER -- MAYO HEALTH SYSTEM N 81175 GAAP LUTHER HOSPITAL A 8750 GAAP LUTHER HOSPITAL L 1253037 GAAP LUTHER HOSPITAL N 383988 GAAP LUTHER HOSPITAL N 245478 GAAP MAYO CLINIC C 69920 GAAP MAYO CLINIC L 12658 GAAP MAYO CLINIC R 99083 GAAP MAYO COLLABORATIVE SERVICES INC L 121027 GAAP MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH G 8629708 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM A 3833 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM L 1029879 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM N 3444066 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM N 264857 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM O 9363 GAAP MMSI INC L 61816 GAAP NORTHWEST WISCONSIN HOMECARE INC A 1186 GAAP NORTHWEST WISCONSIN HOMECARE INC K 33 GAAP NORTHWEST WISCONSIN HOMECARE INC N 2145 GAAP OSSEO MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 30530 GAAP OSSEO MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 15883 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM R 226482 GAAP