2018-08-14T10:06:57-05:00 2017-09-30 861065772 DELOITTE TAX LLP TWO JERICHO PLAZA JERICHO NY 11753 990 2016-10-01 043306782 SIGNATURE HEALTHCARE MEDICAL GROUP INC SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 JAMES PAPADAKOS TREASURER 5089417000 2018-08-09 1 CHRISTINE KAWECKI P00743140 5169187000 2018-08-07 2016 2022-09-23 18:48:47Z SIGNATURE MEDICAL GROUP JAMES PAPADAKOS 680 CENTRE STREET BROCKTON MA 02302 76180575 0 X WWW.SIGNATURE-HEALTHCARE.ORG X 1996 MA TO SUPPORT THE MEDICAL, EDUCATIONAL, SCIENTIFIC AND CHARITABLE PURPOSE OF BROCKTON HOSPITAL. 9 0 781 0 0 0 0 0 95516690 76153942 9398 4845 797520 21788 96323608 76180575 0 0 0 0 82244693 65447301 0 0 0 26699782 23953395 108944475 89400696 -12620867 -13220121 31328742 25134275 18619748 16789786 12708994 8344489 TO SUPPORT THE MEDICAL, EDUCATIONAL, SCIENTIFIC AND CHARITABLE PURPOSE OF BROCKTON HOSPITAL BY IMPROVING ACCESS TO MEDICAL CARE PROVIDED BY THE HOSPITAL. 0 0 81225983 0 76153942 SIGNATURE HEALTHCARE MEDICAL GROUP ("SMG") PHYSICIAN'S PROVIDED EFFICIENT AND HIGH QUALITY PRIMARY AND SPECIALTY HEALTH CARE SERVICES TO RESIDENTS OF ALL AGES, RACES AND ETNIC BACKGROUNDS IN THE COMMUNITIES IN WHICH IT SERVES. 81225983 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 43 0 1 781 1 0 0 0 0 0 0 0 0 0 0 X 9 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MA X X KIM HOLLON 5089417000 680 CENTRE STREET BROCKTON MA 023023395 DAVID DRINKWATER MD PRESIDENT 40.00 2.00 X X 507707 0 31670 MITCHELL SELINGER MD VP 1.00 40.00 X X 0 453824 23959 SYED M IMAM MD DIRECTOR 40.00 0.00 X 1201060 0 45556 AQEEL SIDDIQUI MD DIRECTOR AS OF 1/1/17 40.00 0.00 X 607649 0 23992 SYED TAHIR MD DIRECTOR AS OF 1/1/17 40.00 0.00 X 607545 0 44912 VIKAS TEWARI MD DIRECTOR 40.00 0.00 X 492704 0 40976 AMIN SABET MD DIRECTOR 40.00 0.00 X 211825 0 36139 ALEXANDER GEORGAKIS MD DIRECTOR 40.00 0.00 X 622356 0 43857 ROBERT WEINSTEIN MD CHIEF-FAMILY PRACTICE/EX OFFIC 40.00 0.00 X 642417 0 44586 SONJAY SHRINIVAS DO DIRECTOR, RESIGNED 12/31/16 40.00 0.00 X 372926 0 31184 DAVID KASHMER MD CHIEF-SURG/EX OFF, RESIGNED 10/31/16 40.00 0.00 X 412795 0 8084 AMIT PRASAD MD CQO/EX OFF, RESIGNED 4/30/17 40.00 0.00 X 393762 0 29467 CATHERINE SCHMITT CLERK 1.00 0.00 X 51171 0 0 JAMES PAPADAKOS TREASURER/EX OFFICIO 1.00 41.00 X 0 350788 25589 KYUNG HEE CHANG MD PHYSICIAN 40.00 0.00 X 1068864 0 43395 KERRY GIRARD MD PHYSICIAN 40.00 0.00 X 879555 0 42683 PAUL J PETTINATO MD PHYSICIAN 40.00 0.00 X 921386 0 14226 JEAN-PIERRE GEAGEA MD PHYSICIAN 40.00 0.00 X 699065 0 14226 BORZOO NIKPOOR MD PHYSICIAN 40.00 0.00 X 678944 0 45068 10371731 804612 589569 173 0 1 0 SPUDMAN FERGMEISTER & ASSOCIATES LLC 4023 KENNETT PIKE 58775 WILMINGTON DE 19807 PHYSICIAN SERVICES 342088 MATRIX ANESTHESIA OD 1342 BELMONT STREET BROCKTON MA 02302 PHYSICIAN SERVICES 129000 ALLSCRIPTS LLC 24630 NETWORK PLACE CHICAGO IL 60673 SOFTWARE 104947 3 OUTPATIENT NET REVENUE 900099 69291218 69291218 INTERCOMPANY REVENUES 900099 4486355 4486355 OTHER HEALTHCARE SVCS 900099 1201264 1201264 INTERCOMPANY RENTS 900099 674076 674076 MEANINGFUL USE 900099 501029 501029 76153942 4845 4845 21788 0 21788 21788 21788 76180575 76153942 0 26633 7050834 6698292 352542 49435053 46363263 3071790 709751 669165 40586 5330655 4724506 606149 2921008 2679299 241709 97921 69524 28397 624 443 181 1206307 881630 324677 75242 65688 9554 2915138 2071708 843430 48095 40006 8089 1993767 1415575 578192 2107926 1979400 128526 MD CONTRACTED 7289359 7289359 0 INTERCOMPANY RENT 2238056 1589020 649036 PURCHASED SERVICES 1786259 1312675 473584 MEDICAL & SURGICAL SUPP 1668168 1245162 423006 2526533 2131268 395265 89400696 81225983 8174713 0 4661 4721 143588 258114 5264100 5234452 1426837 1396989 17159620 11385896 11405344 5773724 6414286 7310654 3892916 3438750 2777010 1716871 31328742 25134275 8627984 8005989 216667 108334 9775097 8675463 18619748 16789786 X 12708994 8344489 12708994 8344489 31328742 25134275 X -13220121 8855616 X 0 1 X 1 0 X 75000 75000 43363128 84775367 88858039 95533890 74974465 387504889 43363128 84775367 88933039 95533890 74974465 387579889 0 0 0 387579889 731962 789718 1206109 2727789 43363128 84775367 89665001 96323608 76180574 390307678 0.99300 0.99740 0.00000 0.00000 X 9879077 5774702 4104375 7191995 5611194 1580801 88548 88548 5773724 457B RETIREMENT PLAN 6142561 F 457F MF RETIREMENT PLAN 1168093 F 7310654 DUE FROM THIRD PARTY PAYORS 1701651 SECURITY DEPOSIT 15220 1716871 DEFERRED 457B COMPENSATION 6142561 LEASEHOLD INCENTIVES 1623182 457F MD PLAN INVESTED 317331 457F MD PLAN UNVESTED INTEREST 149041 DEFERRED LONG TERM RENT 443348 8675463 0 1 0 0 0 0 0 1 0 DAVID DRINKWATER MD PRESIDENT 507707 0 0 0 0 0 0 0 31670 0 539377 0 0 0 MITCHELL SELINGER MD VP 0 435541 0 0 0 18283 0 0 0 23959 0 477783 0 0 SYED M IMAM MD DIRECTOR 1195760 0 0 0 5300 0 14372 0 31184 0 1246616 0 0 0 AQEEL SIDDIQUI MD DIRECTOR AS OF 1/1/17 602349 0 0 0 5300 0 13819 0 10173 0 631641 0 0 0 SYED TAHIR MD DIRECTOR AS OF 1/1/17 602245 0 0 0 5300 0 13954 0 30958 0 652457 0 0 0 VIKAS TEWARI MD DIRECTOR 484058 0 0 0 8646 0 12719 0 28257 0 533680 0 0 0 AMIN SABET MD DIRECTOR 207425 0 0 0 4400 0 5181 0 30958 0 247964 0 0 0 ALEXANDER GEORGAKIS MD DIRECTOR 616397 0 0 0 5959 0 12673 0 31184 0 666213 0 0 0 ROBERT WEINSTEIN MD CHIEF-FAMILY PRACTICE/EX OFFIC 632822 0 0 0 9595 0 13628 0 30958 0 687003 0 0 0 SONJAY SHRINIVAS DO DIRECTOR, RESIGNED 12/31/16 372926 0 0 0 0 0 0 0 31184 0 404110 0 0 0 DAVID KASHMER MD CHIEF-SURG/EX OFF, RESIGNED 10/31/16 412795 0 0 0 0 0 0 0 8084 0 420879 0 0 0 AMIT PRASAD MD CQO/EX OFF, RESIGNED 4/30/17 391916 0 0 0 1846 0 0 0 29467 0 423229 0 0 0 JAMES PAPADAKOS TREASURER/EX OFFICIO 0 337143 0 0 0 13645 0 0 0 25589 0 376377 0 0 KYUNG HEE CHANG MD PHYSICIAN 1054421 0 0 0 14443 0 14154 0 29241 0 1112259 0 0 0 KERRY GIRARD MD PHYSICIAN 874255 0 0 0 5300 0 14154 0 28529 0 922238 0 0 0 PAUL J PETTINATO MD PHYSICIAN 913184 0 0 0 8202 0 14154 0 72 0 935612 0 0 0 JEAN-PIERRE GEAGEA MD PHYSICIAN 693765 0 0 0 5300 0 14154 0 72 0 713291 0 0 0 BORZOO NIKPOOR MD PHYSICIAN 669163 0 0 0 9781 0 13970 0 31098 0 724012 0 0 0 PART I, LINE 3 THE STANDING COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE ORGANIZATION'S PARENT, SIGNATURE HEALTHCARE CORPORATION, SERVES AS THE COMPENSATION COMMITTEE OF THE ORGANIZATION AND IS EMPOWERED TO REVIEW AND APPROVE ALL MATTERS PERTAINING TO COMPENSATION AND SHALL REPORT ALL ACTIONS TAKEN BY IT ON THESE MATTERS TO THE BOARD OF TRUSTEES. ANNUALLY, THE COMPENSATION COMMITTEE ENGAGES AN INDEPENDENT COMPENSATION CONSULTING FIRM TO PREPARE AN EXECUTIVE COMPENSATION ANALYSIS WHICH INCLUDES A COMPETITIVE ASSESSMENT OF THE TOTAL COMPENSATION PROGRAM FOR THE ORGANIZATION'S EXECUTIVE POSITIONS (CEO, CFO AND VICE PRESIDENTS) FOR REVIEW BY THE COMPENSATION COMMITTEE. THE MINUTES OF THE COMPENSATION COMMITTEE REFLECT THE DELIBERATIONS AND DECISIONS OF THE COMMITTEE. PART I, LINE 4B SIGNATURE HEALTHCARE CREATED THE 457(F) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN FOR THE PURPOSE OF PROVIDING DEFERRED COMPENSATION FOR A SELECT GROUP OF EMPLOYED PHYSICIANS UPON MEETING THE ELIGIBILITY REQUIREMENT OF COMPLETING TWO YEARS OF PLAN SERVICE. FOR YEARS IN WHICH THE ORGANIZATION MEETS ITS OPERATIONAL MARGIN GOAL THE ORGANIZATION WILL CONTRIBUTE TO THE PLAN. THE ORGANIZATION MAY CREDIT TO THE ACCOUNT OF EACH PARTICIPANT UP TO 4% OF THE PARTICIPANT'S TOTAL CASH COMPENSATION FOR THE PRIOR PLAN YEAR. PARTICIPANT'S REMAIN PARTICIPANTS IN THE PLAN UNTIL FORFEITURE OR DISTRIBUTION OF HIS/HER ACCOUNT. COMMENCEMENT OF DISTRIBUTIONS BEGIN UPON THE LAPSE OF FORFEITURE RISK AND ARE MADE IN SINGLE LUMP-SUM DISTRIBUTIONS NET OF APPLICABLE FEDERAL AND STATE WITHHOLDING TAXES. NO DISTRIBUTIONS WERE MADE FROM THE PLAN TO ANY LISTED PERSONS DURING THE YEAR. PART I, LINE 7 PHYSICIANS ARE ELIGIBLE TO ENTER A PRODUCTIVITY BASED COMPENSATION PLAN ("PLAN") AND BE COMPENSATED BASED ON THE GREATER OF BASE SALARY OR THE PLAN BASED ON PRODUCTIVITY. AN ADDITIONAL INCENTIVE PLAN FOR PHYSICIANS ON PRODUCTIVITY WILL COMPENSATE FOR POSITIVE PERFORMANCE UNDER PATIENT SATISFACTION, QUALITY, AND CITIZENSHIP CRITERIA. FORM 990, PART VI, SECTION A, LINE 6 SIGNATURE HEALTHCARE CORPORATION ("SHC"), A CHARITABLE ORGANIZATION ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS, ACTING THROUGH ITS BOARD OF TRUSTEES, IS THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A SHC, AS SOLE CORPORATE MEMBER, AND ACTING THROUGH ITS BOARD OF TRUSTEES HAS THE POWER TO APPOINT THE ORGANIZATION'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE AUTHORITY OF THE ORGANIZATION'S BOARD OF DIRECTORS TO EXERCISE THE FOLLOWING POWERS IS CONDITIONED ON THE PRIOR APPROVAL OF SHC'S BOARD OF TRUSTEES: APPROVE ANY ACTION IMPACTING THE TAX-EXEMPT STATUS OF SHC OR ITS TAX-EXEMPT AFFILIATES, SHC'S CONFORMANCE WITH LAW OR SHC'S POLICIES; APPROVE PROPOSED OPERATING AND CAPITAL BUDGETS AND STRATEGIC PLANS; APPROVE CHANGES IN METHODOLOGY, STRUCTURE OR PHILOSOPHY OF COMPENSATION PAID AND BENEFITS PROVIDED TO PHYSICIANS; APPROVE THE EXECUTION OF, OR AMENDMENTS TO ANY MATERIAL CONTRACTS; APPROVE THE SALE OR CHANGE OF OWNERSHIP OF THE ORGANIZATION; APPROVE SIGNIFICANT ACQUISITIONS OR DISPOSITIONS OF PROPERTY AND APPROVE INCURRING DEBT ON THE PART OF THE ORGANIZATION FOR MONEY BORROWED OR FOR GUARANTYING THE DEBT OF ANOTHER PARTY. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S FORM 990 IS PREPARED BY AN OUTSIDE INDEPENDENT CERTIFIED PUBLIC ACCOUNTING FIRM AND IS PRESENTED TO AND REVIEWED BY THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER OF SIGNATURE HEALTHCARE CORPORATION. COPIES OF FORM 990 ARE PROVIDED TO EACH MEMBER OF THE BOARD OF TRUSTEES PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES SHALL BE SUBMITTED TO THE PRESIDENT OR HIS DESIGNEE BY DECEMBER 1ST, PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. THE PRESIDENT OR HIS DESIGNEE SHALL, IN WRITING, ADVISE MEMBERS (TRUSTEES, SENIOR MANAGEMENT, DEPARTMENT MANAGERS AND PHYSICIANS) AND INDIVIDUALS ON THE MEDICAL EXECUTIVE COMMITTEE WHO ARE NOT MEMBERS OF THE CONFLICT OF INTEREST POLICY AND REQUEST THAT EACH INDIVIDUAL COMPLETE AND SUBMIT TO THE PRESIDENT OR HIS DESIGNEE, A QUESTIONNAIRE OUTLINING ANY POSSIBLE CONFLICTS OF INTEREST OR INDICATING THAT NO SUCH CONFLICT OF INTEREST EXISTS. THE PRESIDENT OR HIS DESIGNEE SHALL REVIEW ALL CONFLICT OF INTEREST QUESTIONNAIRES AND AT LEAST ANNUALLY DISCLOSE TO THE EXECUTIVE COMMITTEE THE RESULTS OF THE QUESTIONNAIRES. AT LEAST ANNUALLY THE PRESIDENT OR HIS DESIGNEE SHALL REQUEST A COMMITTEE OF THE BOARD TO REVIEW STANDARD RELATIONSHIPS WITH LOCAL BANKS, INSURANCE FIRMS, VENDORS AND OTHER ENTITIES SERVING THE INSTITUTION TO ASSURE THAT THE RELATIONSHIP IS IN THE BEST INTEREST OF THE INSTITUTION AND IS OTHERWISE CONSISTENT WITH THE TERMS OF THE CONFLICT OF INTEREST POLICY. ANY MEMBER HAVING A POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE, USE HIS/HER PERSONAL INFLUENCE OR MAKE AN ADMINISTRATIVE DECISION ON THE MATTER, AND IN THE CASE OF A TRUSTEE, SHOULD NOT BE COUNTED IN DETERMINING THE QUORUM FOR THE ACTION OF THE MATTER. THE MINUTES OF THE MEETING SHOULD REFLECT THAT A FULL AND ACCURATE DISCLOSURE WAS MADE, THAT THE MEMBER ABSTAINED FROM VOTING OR DECISION MAKING AND THE QUORUM OTHERWISE PRESENT. THE CONFLICT OF INTEREST POLICY SHALL BE REVIEWED ANNUALLY BY THE MEMBERS AND EACH NEW MEMBER SHALL BE ADVISED OF THE POLICY PRIOR TO THE INDIVIDUAL'S SELECTION AS A MEMBER, AND SHALL BE REQUIRED TO FILE WITHIN 30 DAYS THEREAFTER A COMPLETED QUESTIONNAIRE. FORM 990, PART VI, SECTION B, LINE 15 THE STANDING COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE ORGANIZATION'S PARENT, SIGNATURE HEALTHCARE CORPORATION, SERVES AS THE COMPENSATION COMMITTEE OF THE ORGANIZATION AND IS EMPOWERED TO REVIEW AND APPROVE ALL MATTERS PERTAINING TO COMPENSATION AND SHALL REPORT ALL ACTIONS TAKEN BY IT ON THESE MATTERS TO THE BOARD OF TRUSTEES. ANNUALLY, THE COMPENSATION COMMITTEE ENGAGES AN INDEPENDENT COMPENSATION CONSULTING FIRM TO PREPARE AN EXECUTIVE COMPENSATION ANALYSIS WHICH INCLUDES A COMPETITIVE ASSESSMENT OF THE TOTAL COMPENSATION PROGRAM FOR THE ORGANIZATION'S EXECUTIVE POSITIONS (CEO, CFO AND VICE PRESIDENTS) FOR REVIEW BY THE COMPENSATION COMMITTEE. THE MINUTES OF THE COMPENSATION COMMITTEE REFLECT THE DELIBERATIONS AND DECISIONS OF THE COMMITTEE. FORM 990, PART VI, SECTION C, LINE 18 FORM 990 IS AVAILABLE FOR PUBLIC INSPECTION ON THE MASSACHUSETTS ATTORNEY GENERAL'S WEBSITE LOCATED AT WWW.MASS.GOV. FORM 990, PART VI, SECTION C, LINE 19 THE ARTICLES OF ORGANIZATION ARE OPEN TO THE PUBLIC ON THE MASSACHUSETTS SECRETARY OF STATE'S WEBSITE AND THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ALSO AVAILABLE ON THE MASSACHUSETTS ATTORNEY GENERAL'S WEBSITE. FORM 990, PART XI, LINE 9: TRANSFERS (TO) FROM AFFILIATES 8,855,616. BROCKTON HOSPITAL INC 680 CENTRE STREET BROCKTON MA 02302 222472997 ACUTE CARE HOSPITAL MA 501(C)(3) 3 SIGNATURE HEALTHCARE CORPORATION 0 SIGNATURE HEALTHCARE CORPORATION INC 680 CENTRE STREET BROCKTON MA 02302 042103554 MANAGEMENT AND FUNDRAISING MA 501(C)(3) 12 N/A 0 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATESINC 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN GROUP MA N/A C 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1