efile Public Visual Render
Submission Date - 2014-08-12
TIN: 03-0179437
Form
990
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
20
12
Open to Public Inspection
A
For the 2012 calendar year, or tax year beginning
10-01-2012
, 2012, and ending
09-30-2013
B
Check if applicable:
Address change
Name change
Initial return
Terminated
Amended return
Application pending
C
Name of organization
Springfield Hospital Inc
Doing Business As
Number and street (or P.O. box if mail is not delivered to street address)
25 Ridgewood Road
Room/suite
City or town, state or country, and ZIP + 4
Springfield
,
VT
05156
D Employer identification number
03-0179437
E Telephone number
(802) 885-7629
G
Gross receipts $
55,532,993
F
Name and address of principal officer:
Andrew Majka
25 Ridgewood Road
Springfield
,
VT
05156
I
Tax-exempt status:
501(c)(3)
501(c)
(
)
(insert no.)
4947(a)(1)
or
527
J
Website:
www.springfieldhospital.org
H(a)
Is this a group return for
affiliates?
Yes
No
H(b)
Are all affiliates included?
Yes
No
If "No," attach a list. (see instructions)
H(c)
Group exemption number
K
Form of organization:
Corporation
Trust
Association
Other
L
Year of formation:
1914
M
State of legal domicile:
VT
Part I
Summary
1
Briefly describe the organizations mission or most significant activities:
25-Bed Critical Access Hospital
2
Check this box
3
Number of voting members of the governing body (Part VI, line 1a)
........
3
13
4
Number of independent voting members of the governing body (Part VI, line 1b)
.....
4
10
5
Total number of individuals employed in calendar year 2011 (Part V, line 2a)
......
5
500
6
Total number of volunteers (estimate if necessary)
.............
6
60
7a
Total unrelated business revenue from Part VIII, column (C), line 12
........
7a
0
b
Net unrelated business taxable income from Form 990-T, line 34
.........
7b
0
Prior Year
Current Year
8
Contributions and grants (Part VIII, line 1h)
.........
288,243
375,471
9
Program service revenue (Part VIII, line 2g)
.........
52,555,016
49,785,775
10
Investment income (Part VIII, column (A), lines 3, 4, and 7d )
....
736,306
1,033,569
11
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)
-3,263
-5,502
12
Total revenueadd lines 8 through 11 (must equal Part VIII, column (A), line 12)
...................
53,576,302
51,189,313
13
Grants and similar amounts paid (Part IX, column (A), lines 13 )
...
0
26,632
14
Benefits paid to or for members (Part IX, column (A), line 4)
.....
0
0
15
Salaries, other compensation, employee benefits (Part IX, column (A), lines 510)
27,770,581
27,189,496
16a
Professional fundraising fees (Part IX, column (A), line 11e)
.....
0
0
b
Total fundraising expenses (Part IX, column (D), line 25)
0
17
Other expenses (Part IX, column (A), lines 11a11d, 11f24e)
....
24,339,713
24,393,825
18
Total expenses. Add lines 1317 (must equal Part IX, column (A), line 25)
52,110,294
51,609,953
19
Revenue less expenses. Subtract line 18 from line 12
.......
1,466,008
-420,640
Beginning of Current Year
End of Year
20
Total assets (Part X, line 16)
.............
43,937,083
45,124,709
21
Total liabilities (Part X, line 26)
.............
22,425,233
21,401,048
22
Net assets or fund balances. Subtract line 21 from line 20
.....
21,511,850
23,723,661
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
2014-08-11
Signature of officer
Date
Andy Majka
CFO
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Barbara J McGuan CPA
Date
2014-08-11
Check
if
self-employed
PTIN
P00219457
Firm's name
Berry Dunn McNeil & Parker LLC
Firm's EIN
01-0523282
Firm's address
PO Box 1100
Portland
,
ME
041041100
Phone no.
(207) 775-2387
May the IRS discuss this return with the preparer shown above? (see instructions)
............
Yes
No
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form
990
(2012)
Form 990 (2012)
Page
2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III
...............
1
Briefly describe the organizations mission:
Our mission is to excel at providing personalized, quality care; where people come first. Our vision is to be the provider of choice by creating a professional environment where patients want to receive care, clinicians want to practice medicine, and employees want to work. We will accomplish this by:* Empowering our caregivers with education, technology, and opportunities for personal and professional development;* Creating an environment which builds collaborative relationships among clinicians, staff, and patients;* Providing our communities with the educational resources and support to make informed decisions and apply preventive care; and* Offering safe, personalized, high quality care.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ?
......................
Yes
No
If Yes, describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services?
............................
Yes
No
If Yes, describe these changes on Schedule O.
4
Describe the organizations program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a
(Code:
) (Expenses $
39,356,265
including grants of $
26,632
) (Revenue $
49,785,775
)
Springfield Hospital (SH) is a 25-bed critical access hospital located in Springfield, VT. SH is a subsidiary of Springfield Medical Care Systems, a seven-site federally qualified health center network. SH also operates The Windham Center, a comprehensive inpatient mental health program in Bellows Falls, VT; off-site physical therapy services, three hospital-owned specialty clinics (ENT, general surgery, and orthopaedics), and an adult day care center in Springfield, VT.SH provides health services to residents throughout its catchment area. Many of the services benefit the elderly, the poor, the indigent, the underinsured, and the uninsured. SH receives minimal reimbursement from these programs, with 62% of Springfield Hospital revenue coming from Medicare and Medicaid funding.Springfield Hospital has a charity care policy under which patients who meet certain criteria will receive care without charge, or at amounts less than established rates. Patients qualify for 100% charity care at up to 200% of the federal poverty guideline (FPG) and 50% assistance up to 300% of the FPG. The Hospital does not bill patients nor pursue collection of amounts determined to qualify as charity care. For FY13, charges foregone for charity care, based on established rates, amounted to $3,500,116.Springfield Hospital also operates a number of specialty practices to provide needed specialty care, to health center patients. These clinics include Connecticut Valley ENT, Surgical Associates, and Connecticut Valley Orthopaedics. In addition, SH provides an outpatient oncology clinic serving patients needing treatment and minimizing their need to travel great distances for medical oncology. Charitable support in the form of gas cards and/or medication cards are provided to patients who do not have needed funds. This program is sponsored through donations and grant funding.Other community benefit programs include the following:Job Training and Shadowing Programs: These programs, in cooperation with Vocational Rehab and training programs through the State of Vermont, provide opportunities to gain on-the-job experience in the healthcare field. We also work with area high school students to provide opportunities for career education and summer employment. Healthcare Scholarships: Springfield Hospital raises funds that are then donated to individuals to further their educational pursuits in healthcare careers. In FY 2013, we donated four scholarships of $1,000 each, and also provide $3,200 annually to AHEC for the MedQuest and Advanced MedQuest programs during the school year.Low Cost Infant Car Seat Program: This program helps residents comply with Vermont's child passenger restraint law, while ensuring the safety of our smallest patients. Approximately 18 infant restraints were provided during FY 2013. We estimate the value of this program to be $900 based on staff time to educate parents on the proper use and installation of the infant car seat and administrative assistant costs.Childbirth Education & Support Groups: The Childbirth Center of Springfield Hospital offers all expectant mothers an opportunity to take a Childbirth Education Class. These free classes are designed to prepare women and their partners for the labor and birth process. Licensed Lactation Consultants provide lactation consulting services.Employee Donations For Community Causes: Throughout the year, the Hospital encourages employees to participate in and donate to fund-raising events in support of various associations that address community needs, like Race for the Cure, Hearts of Hope, food and clothing drives for The Family Center, and the Santa Claus Club. EMS Preceptor Programs: Through Springfield Hospital's Emergency Department, area EMS continue their education by participating in a preceptor program, allowing personnel to observe patient care. In FY 2013, approximately 800 hours of clinical hours were utilized by District 11 EMS personnel. Hospital Based Support Groups: Springfield Hospital provides education and support groups on a variety of topics such as, diabetes education, Alzheimer's, breast cancer, and pulmonary rehabilitation. Group meetings average 8-10 participants and meet monthly for 1-2 hours in duration. These groups are free to participants, educational in nature, offer an opportunity for group discussion, and often include a guest speaker.Meeting Rooms: Free meeting room space is offered to community groups as available. Groups that offer information on health or wellness are given a priority; such as Alcoholics Anonymous, Vermont Department of Health. Training Site Partnerships: Springfield Hospital is a training site for Vermont Technical College for their Licensed Practical Nurses. The following schools also have students doing practicums: University of New Hampshire, University of Vermont, University of Massachusetts, Smith College, Antioch New England Graduate School, River Valley College, VTC, St Joseph's College of Maine, Castleton State College. The program utilization is estimated to exceed 1,700 hours for clinical work. Community Education: Springfield Hospital coordinates health promotion programs, open to the public, for AARP Safe Driver Program and American Heart Association CPR and First Aid classes. Springfield Community: Springfield Hospital encourages employees to become an active volunteer to help improve the communities we call home. Employees donate their time in a variety of areas ranging from serving as Board Members for local groups supporting physical activity, The Family Center, Council on Aging, and Springfield on the Move. Employees also help organize and participate in fundraisers such as The Relay for Life, Susan G. Komen Race For the Cure and the annual Apple Blossom Cotillion. Volunteer Service: Volunteer Services provide a variety of services to patients and visitors. The donation of time and fund-raising activities support programs that include Patient Escort Service, Clerical Services, Activities Support at Adult Day Services, Materials Management Support, and Special Services in the Emergency Department. In 2013, Springfield Hospital had 60 volunteers (including the RSVP Needleworkers). These individuals volunteered a total of 8,300 hours.The Windham Center: The Windham Center is a 10-bed inpatient mental health unit that provides mental health services to residents of Windham and Windsor counties and other communities. Programs provide treatment for men and women who are 18 years of age and older. Multidisciplinary teams include psychiatrists, social workers, clinicians, drug and alcohol counselors, and nurses. Community Health Status Indicators (CHSI) provided by the US Department of Health & Human Services report a suicide rate of 15.6% age-adjusted rate per 100,000 population for Windham Country, VT, and 15.7% for Windsor Country, VT. The Windham Center serves the general population and financial assistance is available, based on need. The Windham Center served 418 patients in 2013, and incurred $151,831 in charity care expense and $342,881 in non-reimbursed Medicaid and Medicare costs for the same time period.Adult Day Care Service: Springfield Hospital operates adult day care service, located in Springfield, VT. A cost-effective choice in long term health care, Adult Day Service assists families with senior or disabled adults, over the age of 18, who face the challenge of losing their independence. The structured program offers a safe and protective environment where nutritious meals, social activities, health care services, nursing oversight, and coordination of needed social and support services are provided. Transportation is available through an arrangement with the local bus service, The Current, at a FY 2013 cost of approximately $28,000. During FY 2013, a total of 115 patients from throughout the region were served by the Adult Day Service.
4b
(Code:
) (Expenses $
including grants of $
) (Revenue $
)
4c
(Code:
) (Expenses $
including grants of $
) (Revenue $
)
4d
Other program services (Describe in Schedule O.)
(Expenses $
including grants of $
) (Revenue $
)
4e
Total program service expenses
39,356,265
Form
990
(2012)
Form 990 (2012)
Page
3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)?
If Yes, complete Schedule A
........................
1
Yes
2
Is the organization required to complete
Schedule B, Schedule of Contributors
(see instructions)?
...
2
Yes
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office?
If Yes, complete Schedule C, Part I
..........
3
No
4
Section 501(c)(3) organizations.
Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year?
If Yes, complete Schedule C, Part II
........
4
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19?
If Yes, complete Schedule C,
Part III
............................
5
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts?
If Yes, complete Schedule D, Part I
........................
6
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures?
If Yes, complete Schedule D, Part II
...
7
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets?
If Yes, complete Schedule D, Part III
....................
8
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services?
If Yes, complete Schedule D, Part IV
..............
9
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments?
If Yes, complete Schedule D, Part V
......
10
Yes
11
If the organizations answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If Yes, complete Schedule D, Part VI.
...................
11a
Yes
b
Did the organization report an amount for investmentsother securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VII
.......
11b
No
c
Did the organization report an amount for investmentsprogram related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VIII
.......
11c
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part IX
............
11d
Yes
e
Did the organization report an amount for other liabilities in Part X, line 25?
If Yes, complete Schedule D, Part X
11e
Yes
f
Did the organizations separate or consolidated financial statements for the tax year include a footnote that addresses the organizations liability for uncertain tax positions under FIN 48 (ASC 740)?
If Yes, complete Schedule D, Part X
.........................
11f
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If Yes, complete Schedule D, Parts XI and XII
.................
12a
Yes
b
Was the organization included in consolidated, independent audited financial statements for the tax year?
If Yes, and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional
12b
Yes
13
Is the organization a school described in section 170(b)(1)(A)(ii)?
If Yes, complete Schedule E
....
13
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?
.....
14a
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more?
If Yes, complete Schedule F, Parts I and IV
.........
14b
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States?
If Yes, complete Schedule F, Parts II and IV
15
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States?
If Yes, complete Schedule F, Parts III and IV
...
16
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e?
If Yes, complete Schedule G, Part I (see instructions)
....
17
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a?
If Yes, complete Schedule G, Part II
............
18
Yes
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a?
If Yes, complete Schedule G, Part III
...................
19
No
20a
Did the organization operate one or more hospital facilities?
If Yes, complete Schedule H
....
20a
Yes
b
If Yes to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
Yes
Form
990
(2012)
Form 990 (2012)
Page
4
Part IV
Checklist of Required Schedules
(continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1?
If Yes, complete Schedule I, Parts I and II
...
21
Yes
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2?
If Yes, complete Schedule I, Parts I and III
........
22
No
23
Did the organization answer Yes to Part VII, Section A, line 3, 4, or 5 about compensation of the organizations current and former officers, directors, trustees, key employees, and highest compensated employees?
If Yes, complete Schedule J
.......................
23
Yes
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002?
If Yes, answer lines 24b through 24d and complete Schedule K. If No, go to line 25
................
24a
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
...
24b
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
......................
24c
d
Did the organization act as an on behalf of issuer for bonds outstanding at any time during the year?
...
24d
25a
Section 501(c)(3) and 501(c)(4) organizations.
Did the organization engage in an excess benefit transaction with a disqualified person during the year?
If Yes, complete Schedule L, Part I
........
25a
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organizations prior Forms 990 or 990-EZ?
If Yes, complete Schedule L, Part I
...................
25b
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organizations tax year?
If Yes, complete Schedule L,
Part II
..........................
26
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons?
If Yes, complete Schedule L, Part III
.........
27
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee?
If Yes, complete Schedule L, Part IV
..........................
28a
No
b
A family member of a current or former officer, director, trustee, or key employee?
If Yes,
complete Schedule L, Part IV
.....................
28b
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner?
If Yes, complete Schedule L, Part IV
...
28c
No
29
Did the organization receive more than $25,000 in non-cash contributions?
If Yes, complete Schedule M
..
29
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions?
If Yes, complete Schedule M
.............
30
No
31
Did the organization liquidate, terminate, or dissolve and cease operations?
If Yes, complete Schedule N,
Part I
...........................
31
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets?
If Yes, complete Schedule N, Part II
......................
32
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3?
If Yes, complete Schedule R, Part I
........
33
No
34
Was the organization related to any tax-exempt or taxable entity?
If Yes, complete Schedule R, Part II, III, or IV, and Part V, line 1
........................
34
Yes
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
No
b
If Yes to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?
If Yes, complete Schedule R, Part V, line 2
...
35b
36
Section 501(c)(3) organizations.
Did the organization make any transfers to an exempt non-charitable related organization?
If Yes, complete Schedule R, Part V, line 2
.............
36
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes?
If Yes, complete Schedule R, Part VI
37
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19?
Note.
All Form 990 filers are required to complete Schedule O.
............
38
Yes
Form
990
(2012)
Form 990 (2012)
Page
5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V
...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable
..
1a
105
b
Enter the number of Forms W-2G included in line 1a.
Enter -0-
if not applicable
.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners?
..................
1c
Yes
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return
..................
2a
500
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note.
If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?
...
3a
No
b
If Yes, has it filed a Form 990-T for this year?
If No, provide an explanation in Schedule O
.....
3b
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
..........................
4a
No
b
If "Yes," enter the name of the foreign country:
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
..
5a
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
No
c
If Yes, to line 5a or 5b, did the organization file Form 8886-T?
............
5c
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?
...
6a
No
b
If Yes, did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?
........................
6b
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?
....................
7a
Yes
b
If Yes, did the organization notify the donor of the value of the goods or services provided?
.....
7b
Yes
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?
...........................
7c
No
d
If Yes, indicate the number of Forms 8282 filed during the year
....
7d
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
............................
7e
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
..
7f
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
............................
7g
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
..........................
7h
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations.
Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?
............
8
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?
..........
9a
b
Did the organization make a distribution to a donor, donor advisor, or related person?
.......
9b
10
Section 501(c)(7) organizations.
Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12
...
10a
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
11
Section 501(c)(12) organizations.
Enter:
a
Gross income from members or shareholders
.........
11a
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.)
..........
11b
12a
Section 4947(a)(1) non-exempt charitable trusts.
Is the organization filing Form 990 in lieu of Form 1041?
12a
b
If Yes, enter the amount of tax-exempt interest received or accrued during the year.
....................
12b
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note.
See the instructions for additional information the organization must report on Schedule O.
13a
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans
....
13b
c
Enter the amount of reserves on hand
............
13c
14a
Did the organization receive any payments for indoor tanning services during the tax year?
.....
14a
No
b
If "Yes," has it filed a Form 720 to report these payments?
If No, provide an explanation in Schedule O
..
14b
Form
990
(2012)
Form 990 (2012)
Page
6
Part VI
Governance, Management, and Disclosure
For each Yes response to lines 2 through 7b below, and for a No response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI
...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
.....................
1a
13
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
...................
1b
10
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee?
.................
2
Yes
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person?
.
3
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
...........................
4
No
5
Did the organization become aware during the year of a significant diversion of the organizations assets?
.
5
No
6
Did the organization have members or stockholders?
................
6
Yes
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body?
....................
7a
Yes
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body?
...................
7b
Yes
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body?
.........................
8a
Yes
b
Each committee with authority to act on behalf of the governing body?
............
8b
Yes
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organizations mailing address?
If Yes, provide the names and addresses in Schedule O
.......
9
No
Section B. Policies
(
This Section B requests information about policies not required by the Internal Revenue Code.
)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates?
............
10a
No
b
If Yes, did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
............................
11a
No
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990.
.....
12a
Did the organization have a written conflict of interest policy?
If No, go to line 13
.......
12a
Yes
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts?
..........................
12b
Yes
c
Did the organization regularly and consistently monitor and enforce compliance with the policy?
If Yes, describe in Schedule O how this was done
.......................
12c
Yes
13
Did the organization have a written whistleblower policy?
...............
13
Yes
14
Did the organization have a written document retention and destruction policy?
.........
14
Yes
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organizations CEO, Executive Director, or top management official
...........
15a
Yes
b
Other officers or key employees of the organization
................
15b
Yes
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year?
......................
16a
No
b
If Yes, did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organizations exempt status with respect to such arrangements?
............
16b
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filed
VT
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
Own website
Another's website
Upon request
Other (explain in Schedule O)
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
Andrew Majka
25 Ridgewood RoadSpringfieldVT05156
(802) 885-7629
Form
990
(2012)
Form 990 (2012)
Page
7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII
...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a
Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organizations tax year.
List all of the organizations
current
officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.
List all of the organizations
current
key employees, if any. See instructions for definition of "key employee."
List the organizations five
current
highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
List all of the organizations
former
officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.
List all of the organizations
former directors or trustees
that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title
(B)
Average hours per week (list any hours for related organizations below dotted line)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(1)
Kevin Anderson
........................................................................
Director
.50
.......................
X
0
0
0
(2)
Kathy Benson
........................................................................
Treasurer
.50
.......................
X
X
0
0
0
(3)
Bob Flint
........................................................................
Director
.50
.......................
X
0
0
0
(4)
Don Hinckley
........................................................................
Director
.50
.......................
X
0
0
0
(5)
Mary Perry
........................................................................
Past Secretary
.50
.......................
.50
X
X
0
0
0
(6)
Albert St Pierre
........................................................................
Director
.50
.......................
.50
X
0
0
0
(7)
Crystal Stokarski
........................................................................
Chairperson
.50
.......................
.50
X
X
0
0
0
(8)
Sarah Vail
........................................................................
Secretary
.50
.......................
.50
X
X
0
0
0
(9)
Glenn Cordner
........................................................................
Past CEO/President
20.00
.......................
20.00
X
X
0
302,247
48,324
(10)
Andrew Majka
........................................................................
CFO & Interim CEO/President
20.00
.......................
20.00
X
X
0
194,840
3,900
(11)
David Muller MD
........................................................................
Director & Orthopaedic Surg
40.00
.......................
X
444,818
0
34,032
(12)
Lori Muse
........................................................................
Vice Chairperson
.50
.......................
.50
X
X
0
0
0
(13)
Katrina Harris DO
........................................................................
Director & Hospitalist Phys
40.00
.......................
X
210,902
0
18,813
(14)
David Sandelman
........................................................................
Director
.50
.......................
X
0
0
0
(15)
Pete Peck
........................................................................
Director
.50
.......................
X
0
0
0
(16)
Sarah Kemble
........................................................................
Chief Medical Officer
40.00
.......................
X
0
171,596
33,503
(17)
George Kopidakis MD
........................................................................
General Surgeon
40.00
.......................
X
310,056
0
29,144
Form
990
(2012)
Form 990 (2012)
Page
8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
(continued)
(A)
Name and Title
(B)
Average hours per week (list any hours for related organizations below dotted line)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(18)
Sara Schaefer MD
........................................................................
Anesthesiologist
40.00
.......................
X
267,161
0
32,892
(19)
Anthony Fazzone MD
........................................................................
Anesthesiologist
40.00
.......................
X
223,237
0
10,572
(20)
John Ciocchi MD
........................................................................
General Surgeon
40.00
.......................
X
232,895
0
29,222
(21)
Ann Bartlett
........................................................................
Anesthesiologist
40.00
.......................
X
244,258
0
14,780
1b
Sub-Total
................
c
Total from continuation sheets to Part VII, Section A
....
d
Total (add lines 1b and 1c)
............
1,933,327
668,683
255,182
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization
26
Yes
No
3
Did the organization list any
former
officer, director or trustee, key employee, or highest compensated employee on line 1a?
If Yes, complete Schedule J for such individual
..............
3
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000?
If Yes, complete Schedule J for such individual
...........................
4
Yes
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization?
If Yes, complete Schedule J for such person
........
5
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organizations tax year.
(A)
Name and business address
(B)
Description of services
(C)
Compensation
Emergency Services of New England
PO Box 12ChesterVT05143
Physician Services
2,244,863
Richard Marasa MD PC
,
1 Walnut Hill CourtSpringfieldVT05156
Physician Services
450,946
Fletcher Allen Healthcare
PO Box 1902BurlingtonVT054021870
Lab Services
416,325
Comprehensive Benefits Administrators
PO Box 2365South BurlingtonVT05407
Benefit Management
407,653
New Hampshire Imaging Services
One Pillsbury St Ste 200ConcordNH03301
Imaging Services
400,956
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization
17
Form
990
(2012)
Form 990 (2012)
Page
9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII
..............
(A)
Total revenue
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from
tax under sections
512, 513, or 514
1a
Federated campaigns
..
1a
b
Membership dues
....
1b
c
Fundraising events
....
1c
10,450
d
Related organizations
...
1d
e
Government grants (contributions)
1e
19,087
f
All other contributions, gifts, grants, and
similar amounts not included above
1f
345,934
g
Noncash contributions included in lines
1a-1f:$
16,297
h
Total.
Add lines 1a-1f
.......
375,471
Business Code
2a
Patient Service Revenue
622110
96,779,740
96,779,740
b
Adult Daycare Revenue
624120
1,306,676
1,306,676
c
Miscellaneous Revenue
622110
374,822
374,822
d
Cafeteria Revenue
622110
139,044
139,044
e
Provision for Bad Debts
622110
-3,969,458
-3,969,458
f
All other program service revenue .
-44,845,049
-44,845,049
g
Total.
Add lines 2a2f
........
49,785,775
3
Investment income (including dividends, interest,
and other similar amounts)
.......
257,122
257,122
4
Income from investment of tax-exempt bond proceeds
..
5
Royalties
...........
(i) Real
(ii) Personal
6a
Gross rents
b
Less: rental expenses
c
Rental income or (loss)
d
Net rental income or (loss)
.......
(i) Securities
(ii) Other
7a
Gross amount from sales of assets other than inventory
5,095,817
b
Less: cost or other basis and sales expenses
4,314,645
4,725
c
Gain or (loss)
781,172
-4,725
d
Net gain or (loss)
..........
776,447
776,447
8a
Gross income from fundraising events (not including
$
10,450
of contributions reported on line 1c).
See Part IV, line 18
..
a
18,808
b
Less: direct expenses
...
b
24,310
c
Net income or (loss) from fundraising events
..
-5,502
-5,502
9a
Gross income from gaming activities.
See Part IV, line 19
...
a
b
Less: direct expenses
...
b
c
Net income or (loss) from gaming activities
...
10a
Gross sales of inventory, less
returns and allowances
.
a
b
Less: cost of goods sold
..
b
c
Net income or (loss) from sales of inventory
..
Miscellaneous Revenue
Business Code
11a
b
c
d
All other revenue
....
e
Total.
Add lines 11a11d
......
12
Total revenue.
See Instructions.
.....
51,189,313
49,785,775
0
1,028,067
Form
990
(2012)
Form 990 (2012)
Page
10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).
Check if Schedule O contains a response to any question in this Part IX
...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII.
(A)
Total expenses
(B)
Program service
expenses
(C)
Management and
general expenses
(D)
Fundraising
expenses
1
Grants and other assistance to governments and organizations in the United States. See Part IV, line 21
26,632
26,632
2
Grants and other assistance to individuals in the United States. See Part IV, line 22
3
Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4
Benefits paid to or for members
5
Compensation of current officers, directors, trustees, and key employees
....
708,565
708,565
6
Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)
....
7
Other salaries and wages
21,012,132
15,600,647
5,411,485
8
Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions)
....
508,013
375,125
132,888
9
Other employee benefits
.......
3,450,983
2,548,218
902,765
10
Payroll taxes
...........
1,509,803
1,120,049
389,754
11
Fees for services (non-employees):
a
Management
......
b
Legal
.........
196,029
196,029
c
Accounting
...........
87,324
87,324
d
Lobbying
...........
e
Professional fundraising services.
See Part IV, line 17
f
Investment management fees
......
60,373
60,373
g
Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)
........
8,380,155
6,571,696
1,808,459
12
Advertising and promotion
....
130,573
130,573
13
Office expenses
.......
203,264
98,887
104,377
14
Information technology
......
15
Royalties
..
16
Occupancy
...........
1,431,315
446,433
984,882
17
Travel
............
43,194
6,333
36,861
18
Payments of travel or entertainment expenses for any federal, state, or local public officials
......
19
Conferences, conventions, and meetings
....
20
Interest
...........
236,916
236,916
21
Payments to affiliates
.......
22
Depreciation, depletion, and amortization
.....
2,234,990
2,184,543
50,447
23
Insurance
..............
481,724
426,224
55,500
24
Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a
Medical supplies
4,759,558
4,592,524
167,034
b
Healthcare Provider tax
2,978,094
2,978,094
c
Other expenses
1,077,836
640,349
437,487
d
Repairs & Maintenance
664,924
580,708
84,216
e
All other expenses
1,427,556
451,238
976,318
25
Total functional expenses.
Add lines 1 through 24e
51,609,953
39,356,265
12,253,688
0
26
Joint costs.
Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation.
Check here
if following SOP 98-2 (ASC 958-720).
Form
990
(2012)
Form 990 (2012)
Page
11
Part X
Balance Sheet
Check if Schedule O contains a response to any question in this Part X
...............
(A)
Beginning of year
(B)
End of year
1
Cashnon-interest-bearing
.............
2,917
1
3,117
2
Savings and temporary cash investments
.........
1,433,119
2
2,628,455
3
Pledges and grants receivable, net
...........
3
4
Accounts receivable, net
.............
8,981,646
4
7,889,207
5
Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L
..................
5
6
Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
6
7
Notes and loans receivable, net
.............
7
8
Inventories for sale or use
..............
354,414
8
398,638
9
Prepaid expenses and deferred charges
..........
562,921
9
643,103
10a
Land, buildings, and equipment: cost or other basis.
Complete Part VI of Schedule D
10a
37,607,919
b
Less: accumulated depreciation
.....
10b
23,351,810
15,219,718
10c
14,256,109
11
Investmentspublicly traded securities
..........
13,301,125
11
12,991,856
12
Investmentsother securities. See Part IV, line 11
.....
12
13
Investmentsprogram-related. See Part IV, line 11
.....
13
14
Intangible assets
...............
14
15
Other assets. See Part IV, line 11
...........
4,081,223
15
6,314,224
16
Total assets.
Add lines 1 through 15 (must equal line 34)
......
43,937,083
16
45,124,709
17
Accounts payable and accrued expenses
.........
4,682,447
17
6,731,434
18
Grants payable
.................
18
19
Deferred revenue
................
19
20
Tax-exempt bond liabilities
.............
7,165,000
20
6,920,000
21
Escrow or custodial account liability.
Complete Part IV of Schedule D
..
21
22
Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons.
Complete Part II of Schedule L
..........
22
23
Secured mortgages and notes payable to unrelated third parties
..
3,602,413
23
3,073,957
24
Unsecured notes and loans payable to unrelated third parties
....
24
1,600,000
25
Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24).
Complete Part X of Schedule D
....................
6,975,373
25
3,075,657
26
Total liabilities.
Add lines 17 through 25
.........
22,425,233
26
21,401,048
Organizations that follow SFAS 117 (ASC 958),
check here
and complete lines 27 through 29, and lines 33 and 34.
27
Unrestricted net assets
..............
20,667,115
27
23,037,738
28
Temporarily restricted net assets
...........
351,244
28
192,432
29
Permanently restricted net assets
...........
493,491
29
493,491
Organizations that do not follow SFAS 117 (ASC 958),
check here
and complete lines 30 through 34.
30
Capital stock or trust principal, or current funds
........
30
31
Paid-in or capital surplus, or land, building or equipment fund
.....
31
32
Retained earnings, endowment, accumulated income, or other funds
32
33
Total net assets or fund balances
...........
21,511,850
33
23,723,661
34
Total liabilities and net assets/fund balances
........
43,937,083
34
45,124,709
Form
990
(2012)
Form 990 (2012)
Page
12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI
...............
1
Total revenue (must equal Part VIII, column (A), line 12)
............
1
51,189,313
2
Total expenses (must equal Part IX, column (A), line 25)
............
2
51,609,953
3
Revenue less expenses. Subtract line 2 from line 1
..............
3
-420,640
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A))
..
4
21,511,850
5
Net unrealized gains (losses) on investments
...............
5
531,672
6
Donated services and use of facilities
.................
6
7
Investment expenses
.....................
7
8
Prior period adjustments
.....................
8
9
Other changes in net assets or fund balances (explain in Schedule O)
........
9
2,100,779
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
23,723,661
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII
..............
Yes
No
1
Accounting method used to prepare the Form 990:
Cash
Accrual
Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organizations financial statements compiled or reviewed by an independent accountant?
2a
No
If Yes, check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
Separate basis
Consolidated basis
Both consolidated and separate basis
b
Were the organizations financial statements audited by an independent accountant?
2b
Yes
If Yes, check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
Separate basis
Consolidated basis
Both consolidated and separate basis
c
If Yes, to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight
of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
b
If Yes, did the organization undergo the required audit or audits?
If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
Yes
Form
990
(2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data
Software ID:
Software Version: