2011-08-03T09:58:46-05:00 2010-12-31 990 2010-01-01 390920634 MAYO CLINIC HEALTH SYSTEM -- NORTHLAND INC MAYO 5075381297 1222 E WOODLAND AVE BARRON WI 548121798 MAURITA A SULLIVAN 7158386465 2011-08-03 2010 2016-03-07 17:11:31Z FKA BARRON MEMORIAL MEDICAL CENTER MAURITA A SULLIVAN 1222 E WOODLAND AVE BARRON WI 548121798 51095318 0 X WWW.LUTHERMIDELFORTNORTHLAND.ORG X 1956 WI HOSPITAL, CLINICS, NURSING HOME AND INDEPENDENT/ASSISTED LIVING CENTER. 11 5 476 105 0 0 178900 65634 42358574 50560514 179915 251930 169559 137503 42886948 51015581 4936 9148 0 0 22502549 28549640 0 0 1262 19818641 17326673 42326126 45885461 560822 5130120 28798979 34277080 6828904 6917855 21970075 27359225 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. 1 0 24332280 34490832 PATIENT CARE (SCHEDULE O)PATIENT CARE: BARRON MEMORIAL MEDICAL CENTER - MAYO HEALTH SYSTEM (D/B/A LUTHER MIDELFORT NORTHLAND (LMN)) IS A MEMBER OF THE MAYO HEALTH SYSTEM. EFFECTIVE MAY 23, 2011 THE FILING ORGANIZATION CHANGED ITS LEGAL NAME TO MAYO CLINIC HEALTH SYSTEM--NORTHLAND. IT IS A WISCONSIN NONPROFIT CORPORATION, TAX EXEMPT AS AN ORGANIZATION DESCRIBED IN SEC. 501(C)(3) OF THE INTERNAL REVENUE CODE. THE CORPORATION, WHICH INCLUDES A HOSPITAL, NURSING HOME AND RETIREMENT HOME, OPERATES PRIMARILY FOR THE RESIDENTS OF BARRON COUNTY AND SURROUNDING COMMUNITIES.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, LMN'S MISSON 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. LMN'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. AS A MEMBER OF MAYO HEALTH SYSTEM, LMN PROVIDES QUALITY HEALTHCARE CLOSE TO HOME WITH DIRECT ACCESS TO HIGHLY SPECIALIZED CARE IF THE NEED ARISES. LMN OPERATES ON A NONDISCRIMINATORY BASIS, REGARDLESS OF RACE, COLOR, SEX, RELIGION OR NATIONAL ORIGIN.THE HOSPITAL PLAYS A VITAL ROLE IN THE HEALTH AND WELL-BEING OF THE COMMUNITY BY OFFERING SERVICES SUCH AS FIVE CLINIC LOCATIONS, 24-HOUR EMERGENCY CARE, SAME DAY SURGERY, FAMILY CENTERED MATERNITY CARE, OB GYN SERVICES, PAIN CLINIC SERVICES, AND ADVANCED DIAGNOSTIC TECHNOLOGY. THE HOSPITAL HAD 1,042 ADMISSIONS INCLUDING ADULTS, CHILDREN, NEWBORN, AND SWING BED ADMISSIONS. THERE WERE OVER 75,657 CLINIC ENCOUNTERS. THERE WERE 1,316 SURGICAL CASES IN 2010, ALONG WITH 145,108 LABORATORY PROCEDURES AND 19,381 IMAGING PROCEDURES PERFORMED IN THE HOSPITAL DURING 2010.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 7,099 DAYS OF SERVICE IN THE NURSING HOME DURING 2010.MAPLECROFT RETIREMENT COMMUNITY IS A REGISTERED RESIDENTIAL CARE APARTMENT COMPLEX (RCAC), OFFERING INDEPENDENT APARTMENTS, AND IF NEEDED, UP TO 28 HOURS PER WEEK OF PERSONAL CARE, SUPPORTIVE CARE, AND NURSING SERVICES TAILORED TO THE NEEDS AND PREFERENCES OF EACH INDIVIDUAL. ADDITIONAL AMENITIES INCLUDE AN EMERGENCY CALL SYSTEM, WEEKLY HOUSEKEEPING SERVICES, LAUNDRY FACILITIES, AND DAILY NOON MEALS. THERE WERE 8 ADMISSIONS TO THE RETIREMENT COMMUNITY DURING 2010, WITH 11,935 DAYS OF SERVICE.AMBULANCE SERVICE: THE AMBULANCE SERVICE IS A HOSPITAL BASED SERVICE WITH THREE AMBULANCES AND PROVIDES EMERGENCY RESPONSE TO THE ENTIRE SURROUNDING COMMUNITY. THERE WERE 626 AMBULANCE RUNS AND 357 INTER-FACILITY TRANSFERS IN 2010. EMT'S ARE ON CALL 24 HOURS PER DAY, 7 DAYS PER WEEK.CHARITY CARE: LMN 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 ALSO PROVIDED FOR PATIENTS THAT ARE FINANCIALLY UNABLE TO PAY FOR SERVICES PROVIDED. THE COST OF CHARITY CARE PROVIDED IN 2010 WAS APPROXIMATELY $766,000. ADDITIONALLY, LMN PROVIDES CARE BELOW COST TO PERSONS COVERED BY MEDICAID. THE UNREIMBURSED COST OF MEDICAID WAS APPROXIMATELY $1,614,100.THE COST OF OTHER MEANS TESTED GOVERNMENT PROGRAMS WAS APPROXIMATELY $6,600. 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. 19183111 9148 16173885 EDUCATION AND OTHER COMMUNITY BENEFITS (SCHEDULE O)EDUCATION AND OTHER COMMUNITY BENEFITS: LMN OFFERS NUMEROUS EDUCATIONAL SEMINARS, CLASSES AND OPPORTUNITIES FOR ITS PATIENTS, THEIR FAMILIES, EMPLOYEES, COMMUNITY MEMBERS AND THE GENERAL PUBLIC. OVER 20,000 AREA RESIDENTS WERE SOMEHOW SERVED BY THE VARIOUS PROGRAMS. SOME EXAMPLES OF OUR COMMUNITY ACTIVITIES INCLUDE:LMN OFFERED PRENATAL CLASSES AND BREASTFEEDING CLASSES FREE OF CHARGE TO LMN PATIENTS, REACHING APPROXIMATELY 105 PEOPLE.LMN STAFF PROVIDED ASSISTANCE WITH SAFETY PRECAUTIONS AND EMERGENCY MEDICAL COVERAGE AT VARIOUS COMMUNITY EVENTS SUCH AS THE RICE LAKE AQUAFEST, BARRON SESQUICENTENTIAL, BARRON HIGH SCHOOL FOOTBALL GAMES, CROSS COUNTRY MEETS, CITY HOCKEY TOURNAMENTS, AND LOCAL PARADES.EDUCATIONAL SEMINARS OFFERED TO AREA RESIDENTS, COMMUNITY GROUPS, AND HEALTH CARE WORKERS INCLUDED THE FOLLOWING PRESENTATIONS: CHOOSING A PRIMARY CARE PROVIDER, DIABETES SELF CARE CLASSES, WELLNESS AND COACHING, MOTIVATIONAL INTERVIEWING, SEXUAL HEALTH PRESENTATION, BECOMING A MASTER JUGGLER, WELLNESS-STOP SMOKING, TAKE CARE OF YOUR WHOLE SELF, TOP TEN HEALTH HABITS ALONG WITH NUMEROUS TOURS, TALKS AND DEMONSTRATIONS FOR AREA ELEMENTARY AND HIGH SCHOOL STUDENTS.BREASTFEEDING SUPPORT GROUP ASSISTED AREA WOMEN NEEDING SUPPORT.PRESENTED HEALTH INFORMATION AT: WITC HEALTH FAIR, CAREER DAY AT CHETEK HIGH SCHOOL, HEALTH CAREER DAY AT LMN, PROVIDER FAIR AT BARRON COUNTY JUSTICE CENTER, BARRON ELECTRIC HEALTH FAIR, MILES FOR LIFE/BACC WALK/RUN, CHILD DEVELOPMENT DAY IN RICE LAKE, JUNIOR ACHIEVEMENT PROGRAM IN CHETEK, PRESCHOOL CHILDREN'S FAIR IN RICE LAKE, CHILDREN'S SAFETY FAIR IN RICE LAKE, AND A FALL PREVENTION CLINIC IN BARRON REACHED 2,800. PROVIDED 2,217 MEALS TO MEALS ON WHEELS AT BELOW COST.VOLUNTEER ACTIVITIES: LMN RECEIVES DONATED SERVICES FROM COMMUNITY VOLUNTEERS. DURING 2010, VOLUNTEERS DONATED OVER 7,000 HOURS OF VOLUNTEER SERVICE TO THE HOSPITAL, VALUED AT APPROXIMATELY $149,520 BASED ON THE INDEPENDENT SECTORS AVERAGE ESTIMATED VALUE OF SUCH SERVICES. THESE SERVICE HOURS WERE SPENT ORGANIZING AND MANAGING ACTIVITIES FOR THE BENEFIT OF BMC'S PATIENTS, PATIENTS' FAMILIES, VISITORS, AND STAFF. 43515391 1 1 0 1 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 1 0 0 0 0 0 0 1 1 1 0 0 1 0 0 476 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 BENNETT MD CRAIG 1.00 X X 0 181197 47042 CADMAN BERWYN 1.00 X 0 0 0 JEROME TRICIA 1.00 X 0 0 0 LARSON MD JOHN L 1.00 X X 0 391684 49204 NOVOTNY RONALD 1.00 X X 0 0 0 PETERSON DONALD 1.00 X X 0 0 0 RAZIM CHERYL 1.00 X X 0 0 0 REISNER MD PETER D 1.00 X 0 212252 50784 SKOLD COLLEEN 1.00 X 0 161337 35703 TRIVEDI MD VIPUL A 1.00 X 0 488597 62493 WHITE PAMELA K 1.00 X X 0 121119 26236 MOMMSEN HUGH 1.00 X 0 0 0 LINTON MD RANDALL L 1.00 X 0 516417 58816 MYERS MD DAVID A 1.00 X 0 217459 50799 SULLIVAN MAURITA A 40.00 X 0 126387 33048 FOSS ANDREW 40.00 X 161327 0 39343 GRAYKOWSKI JOHN 40.00 X 162723 0 29082 LARSON STEPHEN H 40.00 X 220791 0 38550 LILLARD PATRICK H 40.00 X 219405 0 43521 THOMSEN THOMAS J 40.00 X 219441 0 42201 BORMANN DO JOEL X 0 156124 38730 GROSETH BRADLEY D 0.00 X 0 190213 45296 WITTROCK EDWARD A X 0 186054 45891 983687 2948840 736739 15 1 1 0 MAYO FOUNDATION FOR MEDICAL EDUCATION & 200 FIRST STREET SW ROCHESTER MN 55905 PURCHASING AGENT 5605994 MIDELFORT CLINIC LTD -- MAYO HEALTH SY PO BOX 1510 EAU CLAIRE WI 54702 PURCHASED SERVICES 2163176 LUTHER HOSPITAL 1221 WHIPPLE STREET EAU CLAIRE WI 54703 PURCHASED SERVICES 1060177 MAYO COLLABORATIVE SERVICES INC 200 FIRST STREET SW ROCHESTER MN 55905 PURCHASED SERVICES 166001 MMSI INC 200 FIRST STREET SW ROCHESTER MN 55902 PURCHASED SERVICES 113952 5 8978 1332 55324 13687 65634 NET PATIENT REVENUE 620000 50018401 50018401 NURSING HOME REVENUE 623110 507848 507848 RENTAL REVENUE FROM AF 531120 23348 23348 SHARED SERVICES REVENU 561000 6625 6625 EDUCATION REVENUE 611600 4292 4292 50560514 319380 319380 700 68150 -67450 -67450 -67450 10788 8978 5835 4953 4953 3845 733 3112 3112 11214 5019 6195 6195 CAFETERIA/VENDING 722210 78859 78859 MEDICAL RECORD/TRANSCR 541900 23271 23271 MEDICAL DIRECTOR FEES 541900 19040 19040 2073 2073 123243 51015581 50664717 0 285230 9148 9148 22290623 20927071 1362567 985 1330680 1249280 81341 59 3429054 3219293 209609 152 1499283 1407570 91647 66 68230 54473 13757 4176 4176 21297 2337 18960 5 5 5788400 5604569 183831 119464 994 118470 6399493 6250486 149007 133450 118859 14591 1517289 1493289 24000 333201 304412 28789 15811 14882 929 885808 860173 25635 314923 273504 41419 BAD DEBT EXPENSE 1574658 1574658 MEDICAID SURCHARGE 110773 110773 DUES, LICENSES AND SUBS 33495 33495 EMPLOYEE RELATED EXPENS 6200 6120 80 45885461 43515391 2368808 1262 8380 23718 6682468 8094766 145000 183046 227783 48100 54868 18712635 11704965 6531095 7007670 14999652 18372441 346238 350834 28798979 34277080 4363959 4343885 30082 28681 2434863 2545289 6828904 6917855 X 21930182 27316779 39893 42446 21970075 27359225 28798979 34277080 X 5130120 259030 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5 5 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: LOBBYING PORTION OF DUES PAID 1 410 1606 1690 326 1 117001 117001 12987654 8751272 4236382 4801526 2917051 1884475 806454 36642 769812 7007670 MAYO CLINIC INVESTMENT POOL 18372441 F 18372441 DUE TO AFFILIATES 2545289 2545289 Part IV, Line 1b: NURSING HOME RESIDENT FUNDS Part IV, Line 2b: NURSING HOME SECURITY DEPOSITS 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 14503 3715 10788 2829 1819 1187 3 5263 5263 19766 8978 10788 2829 1819 1187 5835 4953 1 1 1 X 1 X 1 1 1 0 1 1 766387 766387 0.01730 5502639 3888539 1614100 0.03640 555076 548485 6591 0.00010 6824102 4437024 2387078 0.05380 75965 4988 70977 0.00160 135600 135600 0.00310 18962398 16030428 2931970 0.06620 9148 9148 0.00020 19183111 16035416 3147695 0.07110 26007213 20472440 5534773 0.12490 0 735552 15501023 15005685 495338 X 1 1 1 1 BARRON MEMORIAL MEDICAL CENTER

1222 EAST WOODLAND BARRON WI 54812

X X X X NOT REQUIRED 1 5 LUTHER MIDELFORT NORTHLAND - BARRON

1222 EAST WOODLAND AVENUE BARRON WI 54812

CLINIC, NURSING HOME, AMBULANCE LUTHER MIDELFORT NORTHLAND -RICE LAKE CL

331 S MAIN STREET SUITE H RICE LAKE WI 548682239

CLINIC LUTHER MIDELFORT NORTHLAND -CHETEK CLINI

220 DOUGLAS STREET CHETEK WI 547280027

CLINIC LUTHER MIDELFORT NORTHLAND - CAMERON CLI

2049 15TH AVENUE CAMERON WI 548224380

CLINIC LUTHER MIDELFORT NORTHLAND -PRAIRIE FARM

224 RIVER AVENUE S PRAIRIE FARM WI 54762

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 PHYSICIAN CLINICS WAS INCLUDED AS SUBSIDIZED HEALTH SERVICES: $1,079,238 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 $ 1574658. PART I LINE 7 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. Part III, Line 4: 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.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.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. 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 CHARITY CARE 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 CHARITY CARE AND OTHER COMMUNITY BENEFIT NEEDS. 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 LMF 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 NORTHLAND (LMN) IS LOCATED IN BARRON, WISCONSIN. ITS SERVICE AREA INCLUDES BARRON COUNTY AND PORTIONS OF RUSK, WASHBURN, SAWYER, AND POLK COUNTIES IN NORTHWESTERN WISCONSIN. LMN IS A DESIGNATED CRITICAL ACCESS HOSPITAL FOR MEDICARE PURPOSES AND IS ONE OF THREE HOSPITALS IN BARRON COUNTY. THE POPULATION OF BARRON COUNTY (WHICH COMPRISES MOST OF LMN'S SERVICE AREA) IS APPROXIMATELY 46,000. ACCORDING TO 2008 CENSUS DATA, APPROXIMATELY 11.6% OF BARRON COUNTY INDIVIDUALS ARE LIVING BELOW POVERTY LEVEL. IN ADDITION, ACCORDING TO THE 2005-2007 WISCONSIN FAMILY HEALTH SURVEY, APPROXIMATELY 15% OF THE BARRON COUNTY POPULATION WAS UNINSURED FOR ALL OR PART OF THE PAST YEAR. ACCORDING TO COUNTY HEALTH RANKINGS "SNAPSHOT: 2010", BARRON COUNTY RANKED 51 OF 72 COUNTIES IN HEALTH OUTCOMES AND 58 OF 72 IN HEALTH FACTORS. BARRON COUNTY IS A FEDERALLY-DESIGNATED MEDICALLY-UNDERSERVED AREA (OR STATE-DESIGNED HEALTH PROFESSIONAL SHORTAGE AREA). Part VI, Line 6: THIS FILING ORGANIZATION 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 CLINIC'S 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 PHSYICIANS 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 HEALTH SYSTEM (WHICH IS PART OF A LARGER GROUP OF ENTITIES AFFILIATED WITH MAYO CLINIC). THE MAYO 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 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 BENNETT MD CRAIG 0 158984 0 4187 0 18026 0 18355 0 28687 0 228239 0 0 LARSON MD JOHN L 0 184896 0 12930 0 193858 0 25170 0 24034 0 440888 0 0 REISNER MD PETER D 0 198371 0 4851 0 9030 0 21687 0 29097 0 263036 0 0 SKOLD COLLEEN 0 159049 0 0 0 2288 0 16022 0 19681 0 197040 0 0 TRIVEDI MD VIPUL A 0 416396 0 19789 0 52412 0 25170 0 37323 0 551090 0 0 LINTON MD RANDALL L 0 461263 0 52400 0 2754 0 25170 0 33646 0 575233 0 0 MYERS MD DAVID A 0 136373 0 4041 0 77045 0 22382 0 28417 0 268258 0 0 SULLIVAN MAURITA A 0 120630 0 3240 0 2517 0 12412 0 20636 0 159435 0 0 FOSS ANDREW 156296 0 5031 0 0 0 16506 0 22837 0 200670 0 0 0 GRAYKOWSKI JOHN 158537 0 3631 0 555 0 16531 0 12551 0 191805 0 0 0 LARSON STEPHEN H 205509 0 15000 0 282 0 22412 0 16138 0 259341 0 0 0 LILLARD PATRICK H 204405 0 15000 0 0 0 22804 0 20717 0 262926 0 0 0 THOMSEN THOMAS J 204441 0 15000 0 0 0 22735 0 19466 0 261642 0 0 0 BORMANN DO JOEL 0 150311 0 4053 0 1760 0 15584 0 23146 0 194854 0 0 GROSETH BRADLEY D 0 174637 0 12615 0 2961 0 19366 0 25930 0 235509 0 0 WITTROCK EDWARD A 0 171312 0 12192 0 2550 0 25148 0 20743 0 231945 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. TERRANCE SULLIVAN FAMILY MEMBER OF MAURITA SULLIVAN, CORPORATE OFFICER 72277 COMPENSATION 0 CONNIE DENNIS FAMILY MEMBER OF MAURITA SULLIVAN, CORPORATE OFFICER 21674 COMPENSATION 0 New Program Services Form 990, Part III, line 2 OPTHAMOLOGY SERVICES, PAIN CLINIC AND OB/GYN SERVICES WERE ADDED IN RICE LAKE. Form 990, Part VI, Section A, line 2 HUGH MOMMSEN AND DONALD PETERSON HAVE A FAMILY RELATIONSHIP. EDWARD WITTROCK AND RANDALL 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: LINTON M.D., RANDALL L. HAS A BUSINESS RELATIONSHIP WITH THE FOLLOWING INDIVIDUALS: BENNETT M.D., CRAIG BORMANN D.O., JOEL GROSETH, BRADLEY D. LARSON M.D., JOHN L. MYERS M.D., DAVID A. REISNER M.D., PETER D. SKOLD, COLLEEN SULLIVAN, MAURITA A. TRIVEDI M.D., VIPUL A. WHITE, PAMELA K. WITTROCK, EDWARD A. 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 SOLE CORPORATE MEMBER MUST APPROVE ANY AMENDMENT TO THE ARTICLES AND BYLAWS IN ADDITION TO THE BOARD OF DIRECTORS. THE BYLAWS PROVIDE THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, AND DEBT, 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, BOARD CHAIR 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 BRADLEY GROSETH 40 HOURS COLLEEN SKOLD 40 HOURS CRAIG BENNETT, M.D. 40 HOURS EDWARD WITTROCK 40 HOURS JOEL BORMANN, D.O. 40 HOURS JOHN L. LARSON, M.D. 40 HOURS PETER REISNER, M.D. 40 HOURS VIPUL TRIVEDI, M.D. 40 HOURS PAM (WOLD) WHITE 40 HOURS DAVID MYERS, M.D. 40 HOURS RANDALL LINTON, M.D. 40 HOURS Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 259,030. 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 1 0 1 1 0 1 1 1 0 1 BLOOMER MEMORIAL MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 81175 GAAP BLOOMER MEMORIAL MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 154078 GAAP LUTHER HOSPITAL A 17861 GAAP LUTHER HOSPITAL K 46925 GAAP LUTHER HOSPITAL N 113101 GAAP LUTHER HOSPITAL N 249639 GAAP LUTHER HOSPITAL L 1060177 GAAP MAYO CLINIC L 14878 GAAP MAYO CLINIC C 38630 GAAP MAYO CLINIC R 319380 GAAP MAYO COLLABORATIVE SERVICES INC L 166001 GAAP MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH G 16337902 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM K 23 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM A 5488 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM O 12654 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM N 193668 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM R 249058 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM L 2163176 GAAP MIDELFORT CLINIC LTD -- MAYO HEALTH SYSTEM N 3988763 GAAP MMSI INC L 113952 GAAP NORTHWEST WISCONSIN HOMECARE INC N 443 GAAP NORTHWEST WISCONSIN HOMECARE INC K 3142 GAAP OSSEO MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 16487 GAAP OSSEO MEDICAL CENTER INC -- MAYO HEALTH SYSTEM N 495 GAAP