2018-05-15T10:16:51-05:00 2017-06-30 593204548 JAMES MOORE & CO PL 2477 TIM GAMBLE PLACE SUITE 200 TALLAHASSEE FL 323084386 990 2016-07-01 571234883 FLORIDA MEDICAL PRACTICE PLAN INC FLOR 8506452827 1115 W CALL ST TALLAHASSEE FL 323064300 OFFICER PRESIDENT 8502247144 2018-05-15 1 KEVIN WARREN P00642409 8503866184 2018-05-14 2016 2022-09-23 18:48:47Z JOHN FOGARTY MD 1115 W CALL ST TALLAHASSEE FL 323064300 4581551 0 X WWW.MED.FSU.EDU/FMPP X 2006 FL THE PURPOSES OF FLORIDA MEDICAL PRACTICE PLAN ARE TO: 1) FURTHER THE EDUCATION, SERVICE, AND RESEARCH MISSIONS OF THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE, A COMPONENT OF THE FLORIDA STATE UNIVERSITY BOARD OF TRUSTEES; AND 2) ENABLE FACULTY TO MAINTAIN CLINICAL COMPETENCE, FULFILL CERTIFICATION REQUIREMENTS, SHARE EXPERTISE WITH OTHER HEALTH CARE PROVIDERS, AND SERVE AS CLINICAL TEACHERS FOR STUDENTS AND RESIDENT PHYSICIANS. 10 0 0 0 0 0 0 0 8844365 4449315 21180 132236 0 0 8865545 4581551 265872 236150 0 0 5117781 2472744 0 0 0 2723137 686221 8106790 3395115 758755 1186436 4234474 5373318 1892473 1844881 2342001 3528437 X THE PURPOSES OF FLORIDA MEDICAL PRACTICE PLAN ARE TO: 1) FURTHER THE EDUCATION, SERVICE, AND RESEARCH MISSIONS OF THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE, A COMPONENT OF THE FLORIDA STATE UNIVERSITY BOARD OF TRUSTEES; AND 2) ENABLE FACULTY TO MAINTAIN CLINICAL COMPETENCE, FULFILL CERTIFICATION REQUIREMENTS, SHARE EXPERTISE WITH OTHER HEALTH CARE PROVIDERS, AND SERVE AS CLINICAL TEACHERS FOR STUDENTS AND RESIDENT PHYSICIANS. 0 0 3354153 236150 4449315 PERFORMED PROFESSIONAL SERVICES IN SUPPORT OF: 1) AN AFFILIATION AGREEMENT WITH A HOSPITAL FOR GRADUATE MEDICAL EDUCATION PROGRAMS, AND 2) AGREEMENTS WITH HEALTH DEPARTMENTS, CLINICS, AND OTHER FOR PATIENT CARE. 3354153 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 16 0 1 0 0 0 0 0 0 0 0 0 0 0 X 10 0 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DAWN SNYDER 8506452827 1115 WEST CALL STREET TALLAHASSEE FL 32306 DANIEL VAN DURME MD VICE PRESIDENT 1.00 40.00 X X 0 289799 38420 ALMA LITTLES MD SECRETARY 1.00 40.00 X X 0 288177 36870 JOHN FOGARTY MD PRESIDENT 2.00 40.00 X X 0 407321 36614 RICHARD NOWAKOWSKI PHD TREASURER 1.00 40.00 X X 0 251201 28885 RICARDO GONZALEZ-ROTHI MD DIRECTOR 1.00 40.00 X 0 269975 21263 LESLIE BEITSCH MD JD DIRECTOR 1.00 40.00 X 0 270957 35619 KYLE CLARK MBA DIRECTOR 0.50 40.00 X 0 340890 38881 SALLIE MCRORIE PHD DIRECTOR 0.50 40.00 X 0 371261 36741 JONATHAN APPELBAUM MD DIRECTOR 1.00 40.00 X 0 251800 35491 PAUL KATZ MD DIRECTOR 1.00 40.00 X 0 294595 36339 KENNETH BRUMMEL-SMITH MD FORMER DIRECTOR 0.00 40.00 X 0 246875 35277 0 3282851 380400 0 1 1 0 0 CLINICAL REVENUE 624100 4398912 4398912 MEDICAID REVENUE 624100 50403 50403 4449315 132236 132236 4581551 4449315 0 132236 236150 236150 1910507 1910507 128116 128116 347454 347454 86667 86667 17500 17500 54753 54753 4978 4978 18484 18484 47946 47946 50900 50900 266676 266676 PROGRAM DEVELOPMENT 202136 202136 BANKING FEES 16338 16338 MEDICAL SUPPLIES 6510 6510 3395115 3354153 40962 0 1034408 563853 407208 381331 36570 52708 1019476 1075209 1736812 3300217 4234474 5373318 36268 35604 4800 0 1851405 1809277 1892473 1844881 X 0 0 0 0 2342001 3528437 2342001 3528437 4234474 5373318 1186436 0 X X 0 1 X 1 0 X X X 1 FLORIDA STATE UNIVERSITY 591961248 2 1 2472744 0 1 2472744 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 FSU FOUNDATION 794284 F FLORIDA SPECIAL PURPOSE INVESTMENT ACCOUNT (VIA UNIVERSITY) 2505933 F 3300217 FLORIDA STATE UNIVERSITY AUXILIARY 640122 DEPARTMENTAL DISTRIBUTION 1169155 1809277 4581551 0 4581551 0 4581551 3395115 0 3395115 0 3395115 EAST ASIA AND THE PACIFIC 0 0 PROGRAM SERVICE. FACULTY TRIP TO COLLABORATE AND SPEAK AT 2016 JAPANESE SOCIETY OF PERSONALITY PSYCHOLOGY. 2668 CENTRAL AMERICA AND THE CARIBBEAN 0 0 PROGRAM SERVICE MEDICAL MISSION FACULTY TRIPS. 6993 NORTH AMERICA 0 0 PROGRAM SERVICE. FACULTY TRIP TO ATTEND SENIORS QUALITY LEAP INITIATIVE CONFERENCE. 976 SOUTH ASIA 0 0 PROGRAM SERVICE. FACULTY TRIP TO COORDINATE AND PARTICIPATE IN INDIAN AGING CONGRESS. 4756 0 0 0 0 0 0 15393 0 15393 0 0 0 0 0 0 0 FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE 1115 WEST CALL STREET TALLAHASSEE FL 32306 591961248 115(1) 236150 DEPARTMENTAL DISTRBUTION SUPPORT 1 0 0 0 0 0 0 0 0 0 DANIEL VAN DURME MD VICE PRESIDENT 0 289799 0 0 0 0 0 23093 0 15327 0 328219 0 0 ALMA LITTLES MD SECRETARY 0 288177 0 0 0 0 0 21543 0 15327 0 325047 0 0 JOHN FOGARTY MD PRESIDENT 0 407321 0 0 0 0 0 21287 0 15327 0 443935 0 0 RICHARD NOWAKOWSKI PHD TREASURER 0 251201 0 0 0 0 0 20217 0 8668 0 280086 0 0 RICARDO GONZALEZ-ROTHI MD DIRECTOR 0 269975 0 0 0 0 0 16502 0 4761 0 291238 0 0 LESLIE BEITSCH MD JD DIRECTOR 0 270957 0 0 0 0 0 20292 0 15327 0 306576 0 0 KYLE CLARK MBA DIRECTOR 0 332190 0 0 0 8700 0 21455 0 17426 0 379771 0 0 SALLIE MCRORIE PHD DIRECTOR 0 364761 0 0 0 6500 0 28833 0 7908 0 408002 0 0 JONATHAN APPELBAUM MD DIRECTOR 0 234750 0 0 0 17050 0 20164 0 15327 0 287291 0 0 PAUL KATZ MD DIRECTOR 0 294595 0 0 0 0 0 21012 0 15327 0 330934 0 0 KENNETH BRUMMEL-SMITH MD FORMER DIRECTOR 0 246875 0 0 0 0 0 19950 0 15327 0 282152 0 0 PART I, LINE 3 COMPENSATION FOR THE ORGANIZATION'S OFFICERS/FACULTY ARE DETERMINED BY THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE AND APPROVED BY FSU'S HUMAN RESOURCE DEPARTMENT (A RELATED ORGANIZATION). THE COMPENSATION IS ESTABLISHED BASED ON BENCHMARKS WITHIN THE INDUSTRY. IN ADDITION, FSU UTILIZES A COMPENSATION COMMITTEE, WRITTEN EMPLOYMENT CONTRACTS AND APPROVAL BY THE BOARD/COMPENSATION COMMITTEE TO ESTABLISH COMPENSATION. FORM 990, PART VI, SECTION A, LINE 2 SALLIE MCRORIE, PH.D. AND KYLE CLARK, MBA ARE ON THE BOARD OF THE FOLLOWING ORGANIZATIONS TOGETHER: FAMU-FSU COLLEGE OF ENGINEERING JOINT MANAGEMENT COUNCIL, FSU INTERNATIONAL PROGRAMS ASSOCIATION, INC. AND THE FSU RESEARCH FOUNDATION, INC. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FINAL FORM 990 WAS PROVIDED TO THE BOARD OF DIRECTORS THROUGH ELECTRONIC MAIL PRIOR TO SUBMITTAL TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, PRINCIPAL, OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS COVERED UNDER THE POLICY. ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST MUST BE DISCLOSED TO THE DIRECTORS, AND THE DIRECTORS WILL DECIDE IF A CONFLICT OF INTEREST EXISTS. IF A MEMBER FAILS TO DISCLOSE A CONFLICT OF INTEREST IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE ORGANIZATION'S TOP OFFICIAL, OFFICERS, AND KEY EMPLOYEES IS DETERMINED BY FAIR MARKET VALUE, SALARY SURVEYS AND A SALARY RANGE PROVIDED BY FLORIDA STATE UNIVERSITY, THE SUPPORTED ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990 PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FLORIDA STATE UNIVERSITY A2201 UNIVERSITY CENTER TALLAHASSEE FL 32306 591961248 UNIVERSITY FL 115 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 FLORIDA STATE UNIVERSITY O 2472744 CASH