Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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| Yes | No | Yes | No | Yes | No | ||||
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| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3.. | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public Support. Subtract line 5 from line 4. | ||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | ||||||
| 11 | Total support (Add lines 7 through 10). | ||||||






| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | ||||||




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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
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| FORM 990, PART C | DOING BUSINESS AS: Essentia Health Brainerd Specialty Clinic | |
| Form 990, Part III, Line 4 | Program service accomplishments: Brainerd Medical Center, Inc. dba Essentia Health Brainerd Specialty Clinic is organized and operated exclusively for charitable and educational purposes. In particular, Essentia Health Brainerd Specialty Clinic operates a medical clinic that provides professional and other health care services, including charitable care to persons unable to pay. Essentia Health Brainerd Specialty Clinic provided over $25,000 in charity care as well as an additional $64,000 in discounts to uninsured patients during the fiscal year ended June 30, 2012. Further community benefits provided during the fiscal year include community services of almost $1,000. Form 990, Part III, Line 4a Program service accomplishments: Essentia Health Brainerd Specialty Clinic employs approximately 160 full time equivalents including 75 physicians who provide services in the specialties of allergy, otolaryngology, family practice, gastroenterology, general surgery, hospitalist, internal medicine, neurology, sleep medicine, obstetrics and gynecology, pediatrics, podiatry, psychiatry, pulmonology, urgent care, convenient care, dietary, audiology, anticoagulation management, and occupational medicine. Essentia Health Brainerd Specialty Clinic was created to facilitate the development of an integrated health care delivery system in Brainerd, Minnesota. Brainerd is a Minnesota community that has a population of 13,000 and is located approximately 150 miles northwest of the Minneapolis - St. Paul Metropolitan area. Essentia Health Brainerd Specialty Clinic had over 189,000 encounters during the fiscal year ended June 30, 2012. Form 990, Part III, Line 4b Program service accomplishments: Essentia Health Brainerd Specialty Clinic operates a retail pharmacy serving both patients and non-patients of Essentia Health Brainerd Specialty Clinic. The pharmacy filled 94,252 scripts during the fiscal year ended June 30, 2012. | |
| Form 990, Part VI, Line 6 | Members of Organization: Essentia Health Central may elect one or more members of the governing body as described in Schedule O Part VI Line 7a. Essentia Health has reserved powers with respect to Essentia Health Brainerd Specialty Clinic as described in Schedule O Part VI Line 7b. | |
| Form 990, Part VI, Line 7a | Member with right to elect governing body: According to its Bylaws, Essentia Health Central shall appoint and remove Essentia Health Brainerd Specialty Clinic's governing body. | |
| Form 990, Part VI, Line 7b | Member with right to approve governing body decision: Essentia Health Brainerd Specialty Clinic is a subsidiary of Essentia Health, whose Board of Directors has reserved powers with respect to this corporation and its subsidiaries, and all of the other direct and indirect subsidiaries of Essentia Health (collectively, the "System"). Essentia Health's reserved powers are as follows: Strategic and Business Plans. Authority to create, and to approve, the System's strategic and business plans. Mission. Authority to create, and to approve, the mission, purpose and vision statements for all entities in the System by the affirmative vote of at least 67% of the Essentia Health board of directors. Debt. Approval of the incurrence of debt by, and the creation of all mortgages, liens, security interests, or other encumbrances on the assets of, all entities in the System in excess of the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors, and the authority to cause all entities in the System to participate in System borrowing. Governing Instruments. Authority to cause, and to approve, amendments of the articles of incorporation and bylaws of all entities in the System. Mergers and Acquisitions. Authority to cause, and to approve, all mergers, consolidations, and dissolutions of all entities in the System. Affiliations and Joint Ventures. Authority to cause, and to approve, all affiliations, joint ventures and other alliances with third parties of all entities in the System. Transfer of Assets Within the System. Authority to transfer assets, including cash, between and among entities within the System; provided, however, that Essentia Health shall not have authority to require any entity in the System to transfer assets (a) that would cause such entity to be in default of its covenants or obligations under any bond or other financing documents; (b) from the Catholic entities to the secular entities or from the secular entities to the Catholic entities in a manner or to an extent that would cause the Catholic entities to be in violation of the Ethical and Religious Directives for Catholic Health Care Services in the judgment of the local ordinary; or (c) such that money generated by services at secular facilities within the System by procedures that are contrary to the Ethical and Religious Directives for Catholic Health Care Services would be used at the Catholic entities or money generated by Catholic entities would be used in the providing of services contrary to the Ethical and Religious Directives for Catholic Health Care Services at secular facilities within the System. Transfer of Assets Outside the System. Authority to cause, and to approve, the sale, lease or other transfer of assets of all entities in the System to parties outside of the System when the asset's value exceeds the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors. Services. Authority to cause, and to approve, the addition of new services and service locations and the discontinuance of services and service locations within all entities in the System. Budgets. Approval of capital and operating budgets of all entities in the System. Professional Services. Selection of the general legal counsel and external auditors of all entities in the System. Acquisitions. Authority to cause, and to approve, all acquisitions by and formations of entities in the System. Marketing. Authority to implement System-wide marketing and promotional activities. Compliance Plans. Authority to create, and to approve, corporate compliance, safety and risk management plans for entities within the System. Quality Plan. Authority to create, and to approve, the System's quality plan. Non-Budgeted Purchases. Approval of non-budgeted capital purchases and leases in excess of the single or annual aggregate dollar limits prescribed in writing by Essentia Health for entities within the System. Human Resources. Authority to create human resource policies and procedures within the System. Reserved Powers. Authority to create additional Essentia Health reserved powers by the affirmative vote of at least 80% of the Essentia Health board of directors (excluding the Essentia Health CEO); provided, however, that any additional Essentia Health reserved powers shall not contravene or hinder the reserved powers of Benedictine Sisters Benevolent Association. | |
| Form 990, Part VI, Line 11a | Form 990 review process: The 2011 Form 990 including all schedules was reviewed by Essentia Health Central's management and governing body on April 2nd, 2013 prior to filing with the Internal Revenue Service. Essentia Health Central Interim Chief Financial Officer led the review of the form and schedules and any questions were discussed. Each current director of the governing body received a final copy of the 2011 Form 990. | |
| Form 990, Part VI, Line 12c | Monitoring and enforcing Conflict of Interest policy: Interested persons annually disclose relationships which might lead to a conflict of interest by completing a conflict of interest disclosure form. Interested persons include any person in a position to exercise substantial influence over the organization. It includes but is not limited to any director, officer, management, employee, or committee member of Essentia Health or any of its affiliates. Essentia is responsible for the annual distribution of conflict of interest forms and review of disclosures for the governing bodies of Essentia and Essentia Operating Members and for senior management employees of Essentia. Transactions with parties with whom a conflict of interest exists may be undertaken only if all of the following are observed: the conflict of interest is fully disclosed; the interested person with the conflict of interest doesn't participate in the approval of such transactions; if practical or appropriate, a competitive bid or comparable valuation is obtained; and the board or committee of the board has determined that the transaction is in the best interest of the organization. Disclosure by any interested person other than a board or committee member should be made to the Chief Executive Officer (or if she/he is the one with the conflict, then to the board chair), who will bring the matter to the attention of the board or an appropriate committee of the board. Disclosure involving board or committee members should be made to the board chair (or if she/he is the one with the conflict, then to the board vice chair), who will bring these matters to the board or an appropriate committee of the board. The board or committee of the board will determine whether a conflict exists and if so, whether the contemplated transaction may be authorized as just, fair, and reasonable to Essentia or its affiliate(s). The decision of the board or a duly constituted committee of the board on these matters will be at its sole discretion, and its concern must be the welfare of Essentia and its affiliate(s) and the advancement of its purposes. The decision of the board is final. If the board determines a conflict does not exist, the interested person may proceed with the transaction; however, he/she will not be eligible to vote on related issues should they arise. If the board determines a conflict does exist, the interested person will be notified of the decision regarding whether the contemplated transaction will be authorized as just, fair, and reasonable. | |
| Form 990,Part VI, Line 15 A & B | Process for determining compensation: The compensation committee of Essentia Health Central's Board of Directors is authorized to fulfill the Board's responsibilities regarding executive compensation consistent with Essentia Health Central's mission, values and tax-exempt status, and the compensation committee's charter. The compensation committee meets at least annually to carry out its responsibilities, which include but are not limited to, establishing, reviewing, and modifying, as appropriate, reasonable compensation and benefits for Essentia Health Central's executive officers and medical staff. The compensation committee engages qualified independent compensation advisors and provide objective and impartial comparative data and to express opinions on the total compensation reasonableness. The compensation committee may request its independent advisors to: monitor comparability data and marketplace trends; make appropriate recommendations regarding salary ranges; and periodically review the market competitiveness of executives' compensation, the compensation committee will obtain and rely upon appropriate data as to comparability of the proposed compensation or adjustments. The compensation committee will adequately document the basis for its determination concurrently with making those determinations. The compensation committee minutes will include: The terms of the approved compensation and the date approved; the compensation committee members present during the review, discussion, and approval of the proposed compensation; identification of the comparability data obtained and relied upon by the compensation and how the data was obtained; any actions by a member of the compensation committee having a conflict of interest; and documentation of the basis for the determination. The year this process was last undertaken for Essentia Health Central's Chief Medical Officer and Essentia Health Brainerd Specialty Clinic's Administrator was 2007. The Executive Compensation Committee of Essentia Health's board of directors is authorized to fulfill the board's responsibilities regarding executive compensation consistent with Essentia's mission, values and tax-exempt status, and the Executive Compensation Committee's Charter. The Executive Compensation Committee meets at least twice annually to carry out its responsibilities, which include, but are not limited to, establishing, reviewing and modifying, as appropriate, reasonable compensation and benefits for Essentia's Chief Executive Officer and his direct reports which are paid by related organizations. The Executive Compensation Committee engages qualified independent compensation advisors to provide objective and impartial comparative data and to express opinions on total compensation reasonableness. The Executive Compensation Committee may request its independent advisors to: monitor comparability data and marketplace trends; make appropriate recommendations regarding salary ranges; and periodically review the market competitiveness of Essentia executive compensation packages. Prior to establishing or adjusting executive compensation, the Executive Compensation Committee will obtain and rely upon appropriate data as to comparability of the proposed compensation or adjustments. The Executive Compensation Committee will adequately document the basis for its determination concurrently with making those determinations. The Executive Compensation Committee minutes will include: the terms of the approved compensation and the date approved; the Executive Compensation Committee members present during the review, discussion and approval of the proposed compensation and those who voted on the proposed compensation; identification of the comparability data obtained and relied upon by the Executive Compensation Committee and how the data was obtained; any actions by a member of the Executive Compensation Committee having a conflict of interest; and documentation of the basis for the determination. The year this process was last undertaken for Essentia Health Central's President was 2010. | |
| Form 990, Part VI, Line 19 | Availability of governing documents, conflict of interest policy, & financial statements to the public: Essentia Health Specialty Clinic makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Essentia Health Specialty Clinic is part of Essentia Health's consolidated financial statements which are included in Essentia Health's annual report posted on Essentia Health's web site. | |
| Form 990, Part VII, Section A, Line 1a, Column B | Hours devoted to related organizations: Peter Dunphy, MD is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. Troy Couture, MD is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. Troy Duininck, MD is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. James Freeman, MD is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. Vanessa Menghini, MD is employed by Essentia Health Specialty Clinic. 100% of her time is spent furthering the purpose of Essentia Health Central and related organizations. William Palmer is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. David Boran, MD is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. Mark Gray, is employed by Essentia Health Specialty Clinic. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. Thomas Prusak is employed by Critical Access Group as Essentia Health Central's President. 100% of his time is spent furthering the purpose of Essentia Health Central and related organizations. | |
| Schedule K | Part 1, Column (f) Description of purpose: Series 2008: Refinance prior notes used to finance a portion of the purchase of the medical clinic located at 2024 S. Sixth Str and to fund the cost of issuance. Series 2009: Refinance prior notes used to finance a portion of the purchase of the medical clinic located at 2024 S. Sixth Str. Part V Procedures to undertake corrective action: Written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program have been subsequently adopted. |
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