2021-11-12T10:22:54-06:00 2020-12-31 PricewaterhouseCoopers LLP 300 Madison Avenue New York NY 10017 990 2020-01-01 208243412 SAMARITAN EMERGENCY MEDICAL SERVICES PC % CHS SERVICES SAMA 5167051931 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 DONALD TEPLITZ CHAIRMAN 5167051919 2021-11-05 true DONALD TEPLITZ 999009999 LAURA J PARELLO P01080295 6464713000 2 2020 2022-09-23 18:48:47Z DONALD TEPLITZ 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 0 false X HTTP://GOODSAMARITAN.CHSLI.ORG/ X 2007 NY WE, AT CHS, HUMBLY JOIN TOGETHER TO BRING CHRISTS HEALING MISSION AND THE MISSION OF MERCY OF THE CATHOLIC CHURCH EXPRESSED IN CATHOLIC HEALTH CARE TO OUR COMMUNITIES. 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10521 -5617 10521 -5617 -10521 5617 963667 1174555 849731 1055002 113936 119553 X SAMARITAN EMERGENCY MEDICAL SERVICES PC IS A MEMBER OF CATHOLIC HEALTH SERVICES OF LONG ISLAND. WE, AT CATHOLIC HEALTH SERVICES, HUMBLY JOIN TOGETHER TO BRING CHRIST'S HEALING MISSION AND THE MISSION OF MERCY OF THE CATHOLIC CHURCH EXPRESSED IN CATHOLIC HEALTH CARE TO OUR COMMUNITIES. I-CARE VALUES INTEGRITY: WE ARE WHO WE SAY WE ARE AND ACT IN ACCORDANCE WITH THE SPLENDOR OF TRUTH OF OUR CATHOLIC MORAL TEACHING AND OUR CATHOLIC VALUES. COMPASSION: WE HAVE COMPASSION FOR OUR PATIENTS, SEE THE SUFFERING CHRIST IN THEM, STRIVE TO ALLEVIATE SUFFERING AND SERVE THE SPRITUAL, PHYSICAL AND EMOTIONAL NEEDS OF OUR PATIENTS. ACCOUNTABILITY: WE TAKE RESPONSIBILITY FOR OUR ACTIONS AND THEIR CONSEQUENCES. RESPECT: WE HONOR THE SANCTITY OF LIFE AT EVERY STAGE OF LIFE AND THE DIGNITY OF EVERY PERSON, AND INCORPORATE ALL THE PRINCIPLES OF CATHOLIC SOCIAL TEACHING IN OUR RELATIONSHIPS AND ADVOCACY. EXCELLENCE: WE SEEK THE GLORY OF GOD IN THE COMPASSIONATE SERVICE OF OUR PATIENTS, AND WE STRIVE TO DO T false false 0 0 0 THROUGH MAY OF 2014, SAMARITAN EMERGENCY MEDICAL SERVICES MANAGED THE EMERGENCY ROOM OF GOOD SAMARITAN HOSPITAL MEDICAL CENTER, A PREMIER HEALTHCARE FACILITY PROVIDING QUALITY HEALTHCARE SERVICES TO THE SOUTH SHORE OF LONG ISLAND. EFFECTIVE MAY 2014 THE MANAGEMENT OF THE EMERGENCY ROOM WAS OUTSOURCED BUT THIS ENTITY CONTINUES TO SUPPORT THE EXEMPT OPERATIONS OF THE HOSPITAL. 0 false false false false false false false false false false false false false true true false true false false false false false false false false false false false true false false false false false false false false false false false false false true false false true 1 0 true 0 false false false false false false false false false false false false X 1 0 false false false false true true true false false false false true true true true true true false false false X CHS SERVICES 5167053700 992 NORTH VILLAGE AVE ROCKVILLE CENTRE NY 11570 DONALD TEPLITZ CHIEF MED OFFICER 50.0 0.0 X X 0 585179 68268 0 585179 68268 0 false true false CHANGE HEALTHCARE LLC PO BOX 74256 ATLANTA GA 30374 COLLECTION SERVICES 449434 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -4886 -4886 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BANK FEES 4267 4267 CORPORATE TAXES -4998 -4998 -5617 0 -5617 0 963667 1174555 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 963667 1174555 203654 90733 0 0 0 0 0 0 0 0 0 0 0 0 0 0 646077 964269 849731 1055002 X 113936 119553 0 0 113936 119553 963667 1174555 5617 X false true X true false 0 DUE TO RELATED PARTIES 388299 THIRD PARTY - MEDICARE PASS THRU 575970 964269 X PART X OTHER LIABILITIES - FIN 48 FOOTNOTE CH AND MOST OF ITS SUBSIDIARIES ARE 501(C)(3) ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE. THESE ENTITIES ARE ALSO EXEMPT FROM NEW YORK STATE INCOME TAXES. THERE ARE VARIOUS SUBSIDIARIES OF CH THAT ARE FOR-PROFIT ENTITIES. TAXABLE OPERATIONS AND THE POTENTIAL FOR INCOME TAXES FROM THESE ENTITIES AND FROM UNRELATED BUSINESS ACTIVITIES OF THE TAX EXEMPT ENTITIES ARE NOT SIGNIFICANT TO THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. false false false false false false false false false DONALD TEPLITZ CHIEF MED OFFICER 0 571007 0 10000 0 4172 0 26961 0 41307 0 653447 0 0 PART I, LINE 3 - METHODS TO ESTABLISH COMPENSATION BY RELATED ORGANIZATION THE FOLLOWING METHODS ARE USED BY A RELATED ORGANIZATION TO ESTABLISH COMPENSATION OF THE CEO/EXECUTIVE DIRECTOR: A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, FORM 990 OF OTHER ORGANIZATIONS, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, LINE 6 - MEMBERS OF THE ORGANIZATION THE CHIEF MEDICAL OFFICER OF GOOD SAMARITAN HOSPITAL IS THE SOLE SHAREHOLDER OF THE SAMARITAN EMERGENCY MEDICAL SERVICES PC, AND IS A NOMINEE SHAREHOLDER AS APPOINTED BY GOOD SAMARITAN HOSPITAL AND CAN BE REPLACED AT WILL. THE SOLE MEMBER OF GOOD SAMARITAN HOSPITAL IS CATHOLIC HEALTH SYSTEM OF LONG ISLAND, (D/B/A/ CATHOLIC HEALTH SERVICES OF LONG ISLAND)(CHS). CHS IS A NEW YORK NOT-FOR-PROFIT CORPORATION ORGANIZED TO SERVE AS THE COORDINATING BODY OF AN INTEGRATED NETWORK OF HEALTHCARE PROVIDERS. CHS IS SPONSORED BY THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTER (DIOCESE). FORM 990, PART VI, LINE 7A - ELECTION OF THE GOVERNING BODY CHS IS THE SOLE MEMBER AND ESTABISHED CO-OPERATOR OF GOOD SAMARITAN HOSPITAL, AND AS SUCH HAS THE RIGHT TO APPOINT THE GOVERNING BODY. THE EMERGENCY DEPARTMENT IS GOVERNED BY THE GOVERNING BODY OF THE HOSPITAL. FORM 990, PART VI, LINE 7B - DECISIONS OF THE GOVERNING BODY CHS, AS THE SOLE MEMBER AND ESTABLISHED CO-OPERATOR OF GOOD SAMARITAN HOSPITAL, IS REQUIRED TO APPROVE CERTAIN DECISIONS MADE BY SAMARITAN EMERGENCY MEDICAL SERVICES PC. FORM 990, PART VI, LINE 8 - DOCUMENTATION OF MEETINGS THE BOARD OF DIRECTORS OF GOOD SAMARITAN HOSPITAL MEDICAL CENTER REVIEW FINANCIAL STATEMENTS AND THE OVERALL OPERATIONS OF THE PC, AND ALSO APPROVE ANY KEY DECISIONS MADE IMPACTING THE PC. MEETINGS HELD AND ACTIONS UNDERTAKEN BY THE GOVERNING BODY OF THE MEDICAL CENTER ARE DOCUMENTED. FORM 990, PART VI, LINE 11B - REVIEW PROCESS FOR FORM 990 THE FORM 990 AND RELATED SCHEDULES ARE COMPLETED BY OUTSIDE TAX ADVISORS AND REVIEWED INTERNALLY BY MANAGEMENT. THE FINAL DRAFT OF THE FORM 990 IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD, AND PRESENTED TO THE COMPLIANCE AND AUDIT COMMITTEE (THE COMMITTEE) OF THE BOARD OF DIRECTORS OF CHS, WHICH HAS BEEN DELEGATED THE FORM 990 REVIEW FUNCTION BY THE BOARD. UPON REVIEW AND RECOMMENDATION OF THE COMMITTEE, THE FORM 990 IS THEN SENT TO THE BOARD FOR APPROVAL. UPON BOARD APPROVAL, THE FORM 990 IS SUBMITTED TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, LINE 12C - CONFLICT OF INTEREST POLICY DISCLOSURE IN ACCORDANCE WITH THE CONFLICT OF INTEREST POLICY (THE POLICY) BY BOARD AND BOARD COMMITTEE MEMBERS, EMPLOYEES AND OTHERS THAT SATISFY THE CRITERIA TO BE CONSIDERED AN INTERESTED PERSON IS SUBMITTED UPON HIRE OR APPOINTMENT AND ANNUALLY THEREAFTER. SUCH INDIVIDUALS HAVE A CONTINUING OBLIGATION TO UPDATE THE INFORMATION PROVIDED DURING THE COURSE OF THE YEAR. A SUMMARY OF DISCLOSURES IS PROVIDED TO THE CHS COMPLIANCE AND AUDIT COMMITTEE BY CHS' COMPLIANCE OFFICER. ALL DISCLOSURES ARE INVESTIGATED AND INFORMATION RELATED TO THE DISCLOSURE IS GATHERED AND SUMMARIZED AND INCLUDED WITH THE SUMMARY OF DISCLOSURES. UPON REVIEW OF THE SUMMARY OF DISCLOSURES, THE CHS COMPLIANCE AND AUDIT COMMITTEE SHALL REPORT ITS FINDINGS TO THE CHS BOARD OF DIRECTORS. THE BOARD SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS BASED ON THE CRITERIA CONTAINED IN THE POLICY. IF A CONFLICT OF INTEREST IS IDENTIFIED AND A MAJORITY OF THE BOARD OR BOARD COMMITTEE AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS AND WISHES TO GO FORWARD WITH IT, THE CHAIR OF THE BOARD OF DIRECTORS SHALL PROVIDE A WRITTEN REQUEST TO THE CHAIR OF THE CHS COMPLIANCE AND AUDIT COMMITTEE, DELINEATING THE TRANSACTION AND CONFLICT AND PROVIDING REASONS WHY THE BOARD AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS, CERTIFIES THAT CHS CANNOT SECURE SIMILAR SERVICES FROM AN ORGANIZATION WITHOUT A CONFLICT, AND WISHES TO GO FORWARD WITH IT. THE PERSON DETERMINED TO HAVE A CONFLICT OF INTEREST MUST RECUSE HIM/HERSELF FROM ANY DECISION MAKING OR VOTING ON THE INTEREST THAT GAVE RISE TO THE CONFLICT. FORM 990,PART VI,LINE 15-COMPENSATION POLICY OF CHS,A RELATED ORG THE CHIEF ADMINISTRATIVE OFFICER SUBMITS FOR APPROVAL TO THE SYSTEM CEO RECOMMENDATIONS FOR BASE SALARY ADJUSTMENTS AND INCENTIVE AWARDS FOR "DISQUALIFIED PERSONS" AS DEFINED IN THE CHS EXECUTIVE COMPENSATION POLICY (COMPENSATION POLICY). THE COMPENSATION POLICY DEFINES A "DISQUALIFIED PERSON" AS A PERSON IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE AFFAIRS OF CHS OR AN OPERATING ENTITY, AND IS EITHER A) A VOTING MEMBER OF THE BOARD OF DIRECTORS OR BOARD OF TRUSTEES; B) THE ENTITY'S PRESIDENT, CHIEF EXECUTIVE OFFICER (CEO), AND CHIEF OPERATING OFFICERS (COO) OR PERSONS HOLDING EQUIVALENT POSITIONS; C) THE ENTITY'S TREASURERS AND CHIEF FINANCIAL OFFICERS (CFO); D) THE PERSON'S COMPENSATION IS PRIMARILY BASED ON REVENUES DERIVED FROM ACTIVITIES OF CHS OR AN OPERATING ENTITY, OR OF A PARTICULAR DEPARTMENT OR FUNCTION OF CHS OR AN OPERATING ENTITY, THAT THE PERSON CONTROLS; E) THE PERSON HAS OR SHARES AUTHORITY TO CONTROL OR DETERMINE A SUBSTANTIAL PORTION OF CHS OR AN OPERATING ENTITY'S CAPITAL EXPENDITURES, OPERATING BUDGET, OR COMPENSATION FOR OTHER EMPLOYEES; F) THE PERSON MANAGES A DEPARTMENT OR ACTIVITY OF CHS OR AN OPERATING ENTITY THAT REPRESENTS A SUBSTANTIAL PORTION OF THE ACTIVITIES, ASSETS, INCOME, OR EXPENSES OF CHS OR AN OPERATING ENTITY, COMPARED TO THE ORGANIZATION AS A WHOLE; OR G) FAMILY MEMBERS OF ANY OF THOSE DESCRIBED IN THE PRECEDING D, E, OR F. ONCE APPROVED BY THE CHS CEO, THESE RECOMMENDATIONS ARE SENT TO THE EXECUTIVE COMPENSATION COMMITTEE OF THE CHS BOARD OF DIRECTORS FOR REVIEW. THE EXECUTIVE COMPENSATION COMMITTEE, WITH AN INDEPENDENT COMPENSATION CONSULTANT ENGAGED BY THE BOARD, WILL REVIEW PROPOSED SALARY ADJUSTMENTS AND INCENTIVE AWARDS TO ENSURE REASONABLENESS BY REVIEWING COMPARABLE TOTAL COMPENSATION DATA (INCLUDING INCENTIVES) PAID TO SIMILARLY SITUATED EXECUTIVES AT THE MEDIAN OF THE DEFINED MARKETPLACE WITH POSSIBLE ADJUSTMENT MADE FOR SPECIAL SKILL, EXPERIENCE, COMPETENCE AND PERFORMANCE, INCLUDING CONTRIBUTION TO THE SYSTEM AS A WHOLE. REVIEWS ARE PERFORMED ANNUALLY BY AN INDEPENDENT CONSULTANT. THE COMPENSATION COMMITTEE SETS STANDARDS TO ENSURE THAT THE CRITERIA USED TO DETERMINE INCENTIVE COMPENSATION ARE SPECIFIC, OBJECTIVE, MEASUREABLE AND RELATED TO INDICATORS OF PERFORMANCE. BASED ON THE INFORMATION PROVIDED, THE COMMITTEE WILL THEN MAKE ITS RECOMMENDATION TO THE CHS BOARD OF DIRECTORS. FORM 990,PART VI,LINE 19 - DOCUMENTS AVAIL. FOR PUBLIC INSPECTION GOVERNING DOCUMENTS-CERTIFICATE OF INCORPORATION FILED WITH NYS DEPARTMENT OF STATE; CHS CONSOLIDATED FINANCIAL STATEMENTS ARE AVAILABLE AT DAC BOND. 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SERVICES 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113224885 HEALTHCARE SVC NY STFRANCIS HOSP C-CORP false SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113307977 HEALTHCARE SVC NY SAMARITAN MGMT C-CORP false SAMARITAN HOME CARE AMERICA 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113319259 HEALTHCARE SVC NY SAMARITAN MGMT C-CORP false MERCY INTERNAL MEDICINE PC 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 510639649 HEALTHCARE SVC NY MERCY MED CTR C-CORP false LONG ISLAND EMERGENCY CARE PC 1000 N VILLAGE AVE ROCKVILLE NY 11571 113633515 PHYSICIAN SVC NY MERCY MED CTR S-CORP false MY CHS RX INC 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 842359236 PHARMACY NY CHSLI C-CORP false false false false false true false false false false false false true false true true false true false false CATHOLIC HEALTH SERVICES OF LONG ISLAND 575970 COST CHS SERVICES INC 248416 COST SCHEDULE R, PART IV FOR ALL PROFESSIONAL CORPORATIONS REPORTED ON SCHEDULE R, PART IV, THE PHYSICIAN IS THE SOLE SHAREHOLDER OF THE ENTITY AND THE DIRECT CONTROLLING ENTITY REPORTED IN COLUMN (D) IS THE BENEFICIAL OWNER. THIS STRUCTURE IS CONSISTENT WITH THE NEW YORK CORPORATE PRACTICE OF MEDICINE.