2017-04-28T17:15:29-05:00 2016-06-30 ERNST & YOUNG US LLP 370 17TH ST 3300 DENVER CO 80202 990 2015-07-01 990326099 Kaua'i Medical Clinic % DEBRA TUQUERO KAUA 8082451500 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 EARL INOUYE VICE PRESIDENT 8082451500 2017-04-28 true Kelley Simon P00791436 7209314000 2015 2021-01-29 14:40:06Z JEN CHAHANOVICH 55 MERCHANT STREET HONOLULU HI 96813 42733455 false X www.hawaiipacifichealth.org/wilcox X 1967 HI THE KAUA'I MEDICAL CLINIC IS A NOT-FOR-PROFIT MULTI-SPECIALTY CLINIC WHOSE MISSION IS TO CREATE A HEALTHIER HAWAI'I. 7 3 265 0 0 210050 49821 40389824 42682774 -512 -4425 468 48 40599830 42728218 0 0 0 0 36456615 39227415 0 0 0 16825318 18745028 53281933 57972443 -12682103 -15244225 12424440 13915878 7714820 8383089 4709620 5532789 X KAUA'I MEDICAL CLINIC IS AN AFFILIATE OF HAWAI'I PACIFIC HEALTH. 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Secretary 0 127774 0 500 0 0 0 6349 0 19266 0 153889 0 0 LORRIE-ANN LUKE VP 0 133999 0 7951 0 15721 0 32517 0 21301 0 211489 0 0 SURENDRA D RAO MD Physician 705634 0 2263 0 10899 0 10600 0 17435 0 746831 0 0 0 JOSEPH M MURRAY MD Physician 557471 0 10684 0 46958 0 10600 0 18407 0 644120 0 0 0 ANDREW SO MD Physician 466708 0 32873 0 66294 0 10600 0 12500 0 588975 0 0 0 DEREK S JOHNSON DO Physician 497931 0 12899 0 30088 0 10600 0 18534 0 570052 0 0 0 ELLIOT M MORRIS MD Physician 456376 0 1197 0 30473 0 7950 0 16656 0 512652 0 0 0 STEVEN ROBERTSON EVP & CIO 0 365310 0 95556 0 140264 0 14828 0 211358 0 827316 0 93921 KATHLEEN A CLARK FORMER OFFICER 0 146444 0 72434 0 69738 0 7358 0 3207 0 299181 0 65147 THERESA L RAMEY FORMER OFFICER 0 120093 0 500 0 1767 0 5796 0 12421 0 140577 0 0 JOHN LA FORGIA FORMER OFFICER 0 57466 0 0 0 345347 0 2145 0 3508 0 408466 0 0 Form 990, Schedule J, Part I, Line 3 THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER IS PAID BY ITS TAX EXEMPT PARENT, HAWAI'I PACIFIC HEALTH ('HPH'), AND IS DISCLOSED AS A PERSON PAID BY A RELATED ORGANIZATION. SEE SCHEDULE O, FORM 990, PART VI, LINE 15A FOR THE PROCESS USED BY HPH TO DETERMINE COMPENSATION. Form 990, Schedule J, Part I, Line 4A SEVERANCE PAY THE FOLLOWING INDIVIDUAL RECEIVED A SEVERANCE PAYMENT FROM A RELATED ORGANIZATION: JOHN LA FORGIA - $303,035 Form 990, Schedule J, Part I, Line 4b THE RESTORATION PLAN WAS DESIGNED TO RESTORE BENEFITS THAT ARE LOST DUE TO LIMITS IMPOSED BY SECTIONS 401 AND 415 OF THE INTERNAL REVENUE CODE ON COMPENSATION CONSIDERED UNDER SUCH PLANS. THE CAPITAL ACCUMULATION ACCOUNT (CAA) IS A SECTION 457(F) PROGRAM THAT WAS PREVIOUSLY AFFORDED TO EXECUTIVE OFFICERS OF THE ORGANIZATION TO PROVIDE BENEFITS ON A TAX DEFERRED BASIS. AMOUNTS PAID OUT DURING THE YEAR BY RELATED ORGANIZATION: RAYMOND P. VARA JR. - $ 132,595 DAVID OKABE - $ 36,249 KENNETH B. ROBBINS, MD - $ 67,410 GAIL LERCH - $ 47,973 CHARLES R. CHING - $ 44,823 STEVEN ROBERTSON - $ 46,143 ARTHUR GLADSTONE - $ 32,570 JENNIE CHAHANOVICH - $ 24,365 KATHLEEN CLARK - $ 28,930 LONG TERM INCENTIVE PLAN THE LONG TERM INCENTIVE PLAN IS AFFORDED TO EXECUTIVES BASED ON ANNUAL AND LONG TERM SYSTEM GOALS THAT ARE NOT BASED ON A PERCENTAGE OF NET EARNINGS. AMOUNTS PAID OUT DURING THE YEAR BY RELATED ORGANIZATION: RAYMOND P. VARA JR. - $ 328,234 DAVID OKABE - $ 117,265 KENNETH B. ROBBINS, MD - $ 115,817 GAIL LERCH - $ 95,858 CHARLES R. CHING - $ 88,416 STEVEN ROBERTSON - $ 95,556 MELINDA ASHTON, MD - $ 81,977 EARL INOUYE - $ 38,502 ARTHUR GLADSTONE - $ 93,476 SUSAN MASUMOTO-NONAKA - $ 34,603 WARREN CHAIKO - $ 38,010 GERI YOUNG, MD - $ 33,670 JENNIE CHAHANOVICH - $ 92,969 KATHLEEN CLARK - $ 72,434 FORM 990, PART III, LINE 4A STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ESTABLISHED IN 1967, KAUA'I MEDICAL CLINIC HAS PROVIDED THE RESIDENTS AND VISITORS OF KAUA'I WITH PRIMARY AND SPECIALTY CARE FOR 49 YEARS. KAUA'I MEDICAL CLINIC PARTNERS WITH WILCOX MEMORIAL HOSPITAL AS PART OF WILCOX HEALTH. KAUA'I MEDICAL CLINIC OFFERS MORE THAN 20 SPECIALTIES AT FIVE LOCATIONS: THE MAIN CLINIC IN LIHU'E, KAUA'I URGENT CARE CLINIC IN LIHU'E AND THREE SATELLITE CLINICS IN KAPA'A, KOLOA AND ELE'ELE. KAUA'I MEDICAL CLINIC EMPLOYS 89 PHYSICIANS AND 155 DIRECT SUPPORT STAFF. IN FISCAL YEAR 2016, TOTAL CLINIC ENCOUNTERS WERE 339,933. SPECIALTY UNITS: KAUA'I MEDICAL CLINIC IS KAUA'I'S ONLY MULTI-SPECIALTY GROUP. IT PROVIDES CARE IN CARDIOLOGY, FAMILY MEDICINE, GASTROENTEROLOGY, GENERAL MEDICINE, GENERAL SURGERY, HEMATOLOGY, INFECTIOUS DISEASES, INTERNAL MEDICINE, NEUROLOGY, OBSTETRICS AND GYNECOLOGY, ONCOLOGY, ORTHOPEDIC SURGERY, OTOLARYNGOLOGY, PEDIATRICS, PHYSIATRY, PODIATRY AND UROLOGY. THIS RANGE OF SPECIALTIES, MULTIPLE LOCATIONS, AND AFFILIATION WITH HAWAI'I PACIFIC HEALTH SIGNIFICANTLY INCREASES ACCESS TO CARE FOR KAUA'I RESIDENTS AND VISITORS. KAUA'I MEDICAL CLINIC PATIENTS ENJOY EASY APPOINTMENT SCHEDULING, URGENT CARE SERVICES, CHRONIC DISEASE MANAGEMENT, DIABETES CONSULTATION AND EDUCATION, DIAGNOSTIC IMAGING AND FINANCIAL COUNSELING. COMMUNITY: KAUA'I MEDICAL CLINIC IS AN ACTIVE COMMUNITY PARTNER. IN FISCAL 2016, ITS HEALTH EDUCATION, PREVENTION PROGRAMS AND SUPPORT GROUPS FOCUSED ON DIABETES, HEART ATTACK/STROKE, SPORTS MEDICINE, WATER SAFETY, INJURY PREVENTION, AND HEALTH FAIRS. TOGETHER WITH WILCOX MEMORIAL HOSPITAL, THE CLINIC HOSTED OR SPONSORED A VARIETY OF COMMUNITY HEALTH EDUCATION EVENTS, AND STAFF SUPPORTED THEIR COMMUNITY BY PARTICIPATING IN ANNUAL CHARITABLE ENDEAVORS. THESE INCLUDED "KIDS SUMMER FEST", "KIDS FEST", "KAUA'I MARATHON KEIKI RUN", SEVERAL PHYSICIAN-LED COMMUNITY WALKS, "KEIKI BIKE AND SAFETY DAY", "CANCER CARE VIDEO TELECONFERENCE", "WOMEN'S WAY TO HEALTH VIDEO TELECONFERENCE", "VALENTINE IN PARADISE VIDEO TELECONFERENCE", AND "OLD KOLOA SUGAR MILL RUN". KAUA'I MEDICAL CLINIC TREATS ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY, THUS SERVING (WITH WILCOX MEMORIAL HOSPITAL) AS ONE OF THE COMMUNITY'S SAFETY NET PROVIDERS OF HEALTH CARE. IN FISCAL YEAR 2016, KAUA'I MEDICAL CLINIC PROVIDED $3,817,961 WORTH OF CARE TO PATIENTS WHO WERE UNINSURED OR UNABLE TO PAY FOR THEIR CARE, AS WELL AS OTHER COMMUNITY BENEFITS. FORM 990, PART V, LINE 1A HAWAI'I PACIFIC HEALTH (HPH), THE ORGANIZATION'S TAX EXEMPT PARENT, PAYS ALL VENDORS. THEREFORE, HPH ISSUES FORM 1099S UNDER ITS TAX ID. FORM 990, PART VI, LINE 6 MEMBERS OR STOCKHOLDERS HAWAI'I PACIFIC HEALTH IS THE SOLE MEMBER WHO HAS THE RIGHT TO PARTICIPATE IN THE ORGANIZATION'S GOVERNANCE WITH THE RIGHT TO ELECT THE MEMBERS OF THE GOVERNING BODY AND/OR APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BODY. FORM 990, PART VI, LINE 7A POWER TO ELECT THE APPOINT MEMBERS HAWAI'I PACIFIC HEALTH IS THE SOLE MEMBER AND HAS THE POWER TO APPROVE THE ELECTION OF MEMBERS OF THE GOVERNING BODY. HAWAI'I PACIFIC HEALTH, AS MEMBER, ALSO HAS THE POWER TO ELECT ONE OR MORE EX OFFICIO VOTING MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, LINE 7B DESITIONS RESERVED TO MEMBERS OR STOCKHOLDERS THE MEMBER SHALL HAVE THE EXCLUSIVE POWER TO TAKE AND DIRECT THE FOLLOWING ACTIONS OF THE CORPORATION: (1) NOMINATE CANDIDATES TO THE BOARD FOR THE FOLLOWING POSITIONS: THE PRESIDENT/CHIEF EXECUTIVE OFFICER, TREASURER, SECRETARY, EXECUTIVE VICE-PRESIDENT/CHIEF FINANCIAL OFFICER, OTHER EXECUTIVE VICE-PRESIDENTS, SENIOR VICE-PRESIDENTS, ASSISTANT SECRETARIES, AND ALL VICE-PRESIDENTS EXCEPT THE OPERATING UNIT VICE-PRESIDENTS, AS SUCH TERM IS DEFINED IN THE BYLAWS; (2) DELEGATE MANAGEMENT AUTHORITIES FROM THE BOARD TO OFFICERS OR COMMITTEES OF THE CORPORATION IN ACCORDANCE WITH A DELEGATED AUTHORITIES MATRIX ADOPTED BY THE MEMBER BOARD; (3) AMEND THE BYLAWS; (4) DETERMINE AND EFFECT THE CORPORATIONS PARTICIPATION IN ALL LONG TERM FINANCING TRANSACTIONS WHICH ARE IN EXCESS OF ONE (1)YEAR AND/OR FOR ONE MILLION DOLLAR ($1,000,000) OR MORE; (5) SELECT BANKS, TRUST COMPANIES, OR OTHER DEPOSITORIES TO WHICH THE CORPORATIONS FUNDS SHALL BE DEPOSITED; (6) DIRECT, MANAGE AND CONTROL THE CUSTODY, ADVISORY SERVICE AND ASSET MANAGEMENT OF THE FINANCIAL ASSETS OF THE CORPORATION; (7) EFFECT INTER-CORPORATE TRANSFERS BY AND BETWEEN THE CORPORATION AND ANY AFFILIATE; (8) DEVELOP AND IMPLEMENT THE GENERAL POLICIES REGARDING THE CORPORATIONS PHYSICIAN AND EXECUTIVE COMPENSATION AND BENEFIT PLANS; (9) FORM A NEW CORPORATION, LIMITED LIABILITY COMPANY, OR PARTNERSHIP OR OTHER ORGANIZATION THAT IS OWNED SOLELY BY THE CORPORATION; (10) EXCEPT AS OTHERWISE PROVIDED IN THE BYLAWS OR AS REQUIRED BY THE LAW OF THE STATE OF HAWAI`I, SELL, LEASE OR OTHERWISE TRANSFER FIFTY PERCENT (50%) OR MORE OF THE THEN CURRENT AMOUNT, AS REPORTED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, OF THE TOTAL ASSETS HELD BY WILCOX MEMORIAL HOSPITAL, KAUAI MEDICAL CLINIC AND WILCOX HEALTH FOUNDATION (THE "WILCOX AFFILIATES"); (11) EXCEPT AS PROVIDED IN THE BYLAWS OR AS REQUIRED BY THE LAWS OF THE STATE OF HAWAI`I, SELL, LEASE OR TRANSFER OF OPERATIONS OR ACTIVITIES OF THE WILCOX AFFILIATES WHICH GENERATE FIFTY PERCENT (50%) OR MORE OF THE TOTAL NET REVENUES, AS REPORTED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, OF THE WILCOX AFFILIATES DURING THE PRIOR FISCAL YEAR; (12) CLOSE THE CLINICAL FACILITIES OWNED AND OPERATED BY THE CORPORATION; PROVIDED, THAT, AFTER THE EFFECTIVE DATE OF THE BYLAWS, ANY ELIMINATION OF A CLINICAL SERVICE PROVIDED BY THE CORPORATION MUST ALSO BE APPROVED BY THE BOARD; (13) CONVERT THE CLINIC OWNED AND OPERATED BY THE CORPORATION INTO A FACILITY NO LONGER OFFERING MEDICAL SERVICES; PROVIDED, THAT, AFTER THE EFFECTIVE DATE OF THE BYLAWS, ANY ELIMINATION OF A CLINICAL SERVICE PROVIDED BY THE CORPORATION MUST ALSO BE APPROVED BY THE BOARD; (14) AFTER CONSULTING WITH THE BOARD, REMOVE THE PRESIDENT/CHIEF EXECUTIVE OFFICER, EXECUTIVE VICE-PRESIDENT/CHIEF FINANCIAL OFFICER, TREASURER, SECRETARY, OTHER EXECUTIVE VICE-PRESIDENTS, SENIOR VICE-PRESIDENTS, ASSISTANT SECRETARIES, AND ALL VICE-PRESIDENTS EXCEPT THE OPERATING UNIT VICE-PRESIDENTS; PROVIDED, HOWEVER, THAT TO REMOVE OR TERMINATE THE PRESIDENT/CHIEF EXECUTIVE OFFICER WILL REQUIRE THE PRESIDENT/CHIEF EXECUTIVE OFFICER OF THE MEMBER TO FULLY COLLABORATE AND CONSULT WITH THE BOARD AND SEEK THE BOARD'S ADVANCE CONSENT FOR SUCH REMOVAL OR TERMINATION. IF THE BOARD DOES NOT CONCUR WITH THE PROPOSED REMOVAL OR TERMINATION OF THE PRESIDENT/CHIEF EXECUTIVE OFFICER, SUCH REMOVAL OR TERMINATION WILL REQUIRE THE APPROVAL OF A MAJORITY OF THE MEMBERS ON THE MEMBER BOARD; (15) AFTER CONSULTING WITH THE BOARD, DEVELOP AND PROMULGATE THE CORPORATE GOALS AND THE LONG RANGE AND STRATEGIC PLANS OF THE CORPORATION; AND (16) AFTER CONSULTING WITH THE BOARD, DEVELOP AND IMPLEMENT THE ANNUAL CAPITAL, OPERATING, AND CASH FLOW BUDGETS. THE CORPORATION SHALL NOT TAKE THE FOLLOWING ACTIONS WITHOUT FIRST OBTAINING MEMBER BOARD APPROVAL: (1) ADD ANY DIRECTOR TO THE BOARD; (2) REMOVE ANY DIRECTOR FROM THE BOARD; (3) AMEND THE ARTICLES; (4) ENTER INTO ANY UNBUDGETED CONTRACTS ON BEHALF OF THE CORPORATION WHICH REQUIRE ANNUAL PAYMENTS ON BEHALF OF THE CORPORATION EXCEEDING ONE MILLION DOLLARS ($1,000,000) IN VALUE; (5) ACQUIRE ASSETS WORTH OVER ONE MILLION DOLLARS ($1,000,000); (6) ACQUIRE SHARES IN ANOTHER CORPORATION; (7) SELL, LEASE OR OTHERWISE TRANSFER FIFTY PERCENT (50%) OR MORE OF THE THEN CURRENT AMOUNT, AS REPORTED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, OF THE TOTAL ASSETS HELD BY THE WILCOX AFFILIATES; (8) SELL, LEASE, EXCHANGE OR DISPOSE OF FIFTY PERCENT (50%) OR MORE OF THE PROPERTY AND ASSETS HELD BY THE CORPORATION TO ANY ENTITY THAT IS NOT AN AFFILIATE; (9) SELL, LEASE OR TRANSFER OF OPERATIONS OR ACTIVITIES OF THE WILCOX AFFILIATES WHICH GENERATE FIFTY PERCENT (50%) OR MORE OF THE TOTAL NET REVENUES, AS REPORTED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, OF THE WILCOX AFFILIATES DURING THE PRIOR FISCAL YEAR; (10) MERGE THE CORPORATION WITH ANY ENTITY; (11) DISSOLVE OR LIQUIDATE THE CORPORATION; (12) ISSUE THE CORPORATIONS MEMBERSHIP TO ANYONE OTHER THAN THE MEMBER; (13) FORM A JOINT VENTURE OR OTHER BUSINESS RELATIONSHIP (OTHER THAN THE ORDINARY COURSE OF BUSINESS CONTRACTS) BETWEEN THE CORPORATION AND ANY PERSON OR ENTITY; AND (14) DEVELOP A NEW LINE OF BUSINESS OR A NEW SERVICE. FORM 990, PART VI, LINE 11B PROCESS USED TO REVIEW THE FORM 990 VARIOUS SCHEDULES OF THE 990 ARE PREPARED PRIMARILY BY STAFF WITHIN THE ACCOUNTING AREA OF THE ORGANIZATION WORKING WITH VARIOUS OTHER AREAS OF THE ORGANIZATION SUCH AS MANAGEMENT OF THE OPERATING UNITS, HR, LEGAL, ETC. DISCLOSURE NARRATIVES ARE WRITTEN AND COMPILED INTERNALLY BASED ON INPUT AND DISCUSSION WITH FINANCIAL ANALYSTS AND THE CHIEF OPERATING OFFICER/EXECUTIVE DIRECTOR OF THE REPORTING ENTITY. THE CHIEF OPERATING OFFICER/EXECUTIVE DIRECTOR OF EACH REPORTING ENTITY REVIEWS AND APPROVES THE DISCLOSURE NARRATIVES WHICH DESCRIBES THE MISSION/PURPOSE AND PROGRAM ACCOMPLISHMENTS OF THEIR ORGANIZATION. SENIOR MANAGEMENT OF THE HEALTH CARE SYSTEM REVIEWS THE 990S OF EACH FILING ORGANIZATION WITHIN THE HEALTH CARE SYSTEM. ONCE SENIOR MANAGEMENT HAS COMPLETED ITS REVIEW, THE 990S ARE THEN PROVIDED TO THE GOVERNANCE AND NOMINATING COMMITTEE OF THE HEALTH CARE SYSTEM'S BOARD OF DIRECTORS FOR THEIR REVIEW. THE GOVERNANCE AND NOMINATING COMMITTEE OF THE PARENT ENTITY'S (HAWAI'I PACIFIC HEALTH "HPH") BOARD PROVIDES OVERSIGHT FOR THE 990 REPORTING AND REVIEWS THE 990S FOR EACH ENTITY PRIOR TO FILING. IN ADDITION, THE 990S FOR EACH ENTITY ARE MADE AVAILABLE TO THE BOARD MEMBERS OF EACH SUBSIDIARY UNIT OF HPH AND THE HPH BOARD OF DIRECTORS THROUGH A BOARD MEMBER PORTAL FOR REVIEW PRIOR TO THE FILING OF THE 990. THE 990S WILL BE POSTED TO HPH'S WEB SITE FOR PUBLIC ACCESS AFTER THE FILING OF THE RETURN WITH THE IRS. FORM 990, PART VI, LINE 12C MONITORING & ENFORCEMENT OF COMPLIANCE WITH CONFLICT OF INTEREST POLICY ANNUALLY, EACH DIRECTOR, OFFICER, KEY EMPLOYEE AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) RECEIVED A COPY OF THE CONFLICT OF INTEREST ("COI") POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) HAS DISCLOSED ANY CONFLICTS OR POTENTIAL CONFLICTS OR ECONOMIC INTERESTS AS REQUIRED; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, THE ORGANIZATION MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. THE IN-HOUSE LEGAL DEPARTMENT DISTRIBUTES THE STATEMENT REQUEST AND REVIEWS THE COI STATEMENTS RETURNED. IDENTIFIED CONFLICTS OF INTEREST ARE PRESENTED TO THE BOARD FOR REVIEW, DELIBERATION AND CONFIRMATION/REFUTATION THAT A CONFLICT OF INTEREST EXISTS. IF A CONFLICT OF INTEREST HAS BEEN FOUND, THE INDIVIDUAL MAY ADDRESS THE BOARD AND EXPLAIN THE TRANSACTION OR ARRANGEMENT CAUSING THE CONFLICT. AFTER THE PRESENTATION, THE INDIVIDUAL IS EXCUSED FROM THE MEETING AND SHALL NOT PARTICIPATE WITH ANY DISCUSSION OR VOTE ON MATTERS PERTAINING TO THE TRANSACTION OR ARRANGEMENT. IN MEETINGS WHERE APPLICATION OF THE COI POLICY OCCURS, THE MEETING MINUTES INCLUDE NATURE OF THE FINANCIAL INTEREST/CONFLICT, NAME(S) OF THE PERSON(S) WITH THE POTENTIAL OR ACTUAL CONFLICT, ANY ACTION TAKEN TO ASSIST IN THE DETERMINATION OF WHETHER A CONFLICT EXISTED, INCLUDING ANY DISCUSSION OF ALTERNATIVE ARRANGEMENTS, THE BOARD'S DECISION(S) REGARDING THE CONFLICT AND NAMES OF PERSON PRESENT IN THE DISCUSSION AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, LINE 15 PROCESS OF DETERMINING COMPENSATION THE CEO OF THE ORGANIZATION IS NOT COMPENSATED BY THE FILING ORGANIZATION, BUT RATHER BY THE TAX EXEMPT PARENT HAWAI'I PACIFIC HEALTH ("HPH"). FOLLOWING IS THE PROCESS THAT THE PARENT ORGANIZATION UNDERTAKES TO APPROVE THE CEO'S COMPENSATION. COMPENSATION FOR HAWAI'I PACIFIC HEALTH ("HPH") EXECUTIVES (VICE PRESIDENT AND ABOVE) IS SET BY THE HPH COMPENSATION COMMITTEE, WHICH IS COMPOSED SOLELY OF INDEPENDENT, COMMUNITY-BASED MEMBERS OF THE HPH BOARD OF DIRECTORS. ON AN ANNUAL BASIS, THE HPH BOARD CHAIRPERSON (WHO IS INDEPENDENT) SELECTS A NEUTRAL THIRD PARTY EXECUTIVE COMPENSATION CONSULTANT TO REVIEW THE EXECUTIVES' COMPENSATION AND BENEFITS. THE CONSULTANT PROVIDES A WRITTEN REPORT TO THE COMPENSATION COMMITTEE AT ITS ANNUAL MEETING. INCLUDED IN THE REPORT IS MARKET BASED DATA FROM LIKE ORGANIZATIONS. THE COMPENSATION COMMITTEE MAKES FINAL DECISIONS REGARDING COMPENSATION AND BENEFITS AT THE MEETING AFTER REVIEW AND DISCUSSION OF THE CONSULTANT'S REPORT, AND SUCH DECISIONS ARE DOCUMENTED IN THE COMPENSATION COMMITTEE MEETING MINUTES. COMMUNITY BASED DIRECTORS OF THE ORGANIZATION ARE NOT COMPENSATED. CERTAIN EMPLOYED PHYSICIANS MAY BE OFFICERS OR AN IDENTIFIED KEY EMPLOYEE OF THE REPORTING OR RELATED ORGANIZATION. PHYSICIAN COMPENSATION IS ALSO HANDLED IN THE SAME MANNER AS EXECUTIVE COMPENSATION, WITH THE HPH COMPENSATION COMMITTEE RECEIVING A REPORT FROM A NEUTRAL CONSULTANT AND FOLLOWING THE SAME PROCESS AS DESCRIBED ABOVE ON AN ANNUAL BASIS. THIS PROCESS WAS COMPLETED ON MARCH 11, 2016 TO REVIEW PHYSICIAN COMPENSATION, AND ON AUGUST 24, 2016 TO REVIEW EXECUTIVE COMPENSATION. FORM 990, PART VI, LINE 19 PROCESS OF MAKING DOCUMENTS AVAILABLE TO THE PUBLIC THE CONFLICT OF INTEREST POLICY AND STANDARDS OF CONDUCT ARE AVAILABLE ON THE HAWAI'I PACIFIC HEALTH WEBSITE. THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC VIA THE HAWAI'I PACIFIC HEALTH WEBSITE. FORM 990, PART IX, LINE 11G OTHER FEES EXCEEDING 10% OF TOTAL EXPENSE 3,535,720 - INTERNAL SERVICE PROVIDER 787,606 - PHYSICIAN SERVICES 587,344 - SERVICES PROVIDED BY WMH STAFF FOR ENVIRONMENTAL SERVICES, JANITORIAL, DISPOSAL SHREDDING, PEST CONTROL & CLEANING SERVICE 471,122 - SERVICES PROVIDED BY WMH STAFF FOR HEALTH INFO MGMT 350,316 - REPAIRS & MAINTENANCE 347,100 - VARIOUS SERVICES 242,266 - URGENT CARE STAFF HOURS 215,868 - COURIER SERVICES, PURCHASE TECH/CLERK HOURS, STERILE CLEANING SUPPLIES/INSPECT & PACKAGE SUPPLIES 211,302 - ELECTRICAL, SERVICES PROVIDED BY WMH STAFF FOR PLANT/GROUND MAINTENANCE, SECURITY SERVICES 108,172 - SERVICE EXCELLENCE 48,526 - COLLECTION FEES 42,625 - CONSULTING 42,453 - SERVICES CONTRACT RECURRING 39,700 - SERVICES TEMP LABOR OTHER 18,149 - LAUNDRY 650 - BUS PASS (329) - SERVICES MEDICAL (1,159) - EXPENSE RECOVERY --------------- 7,047,431 TOTAL FORM 990, PART XI, LINE 9 OTHER CHANGES IN NET ASSETS 16,067,394 - EQUITY TRANSFERS WITH HPH ----------- 16,067,394 TOTAL KAPI'OLANI HEALTH FOUNDATION 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990246364 FUNDRAISING HI 501(c)(3) 7 NA true KAPI'OLANI MEDICAL CTR WOMEN & CHILDREN 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990177350 HOSPITAL HI 501(c)(3) 3 NA true KAPI'OLANI MEDICAL SPECIALISTS 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990322406 HEALTH CARE HI 501(c)(3) 9 NA true PALI MOMI FOUNDATION 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 383840327 FUNDRAISING HI 501(c)(3) 7 NA true PALI MOMI MEDICAL CENTER 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990274038 HOSPITAL HI 501(c)(3) 3 NA true PROVIDERS INSURANCE CORPORATION 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 710893000 INSURANCE HI 501(c)(3) 11B, II NA true STRAUB CLINIC & HOSPITAL 55 MERCHANT STREET 24TH FLOOR HONOLULUL HI 96813 912151670 HOSPITAL HI 501(c)(3) 3 NA true STRAUB FOUNDATION 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990109350 RESEARCH/EDUC HI 501(c)(3) 7 NA true WILCOX HEALTH FOUNDATION 3-3420 LIHUE HIGHWAY LIHUE HI 96766 990204242 FUNDRAISING HI 501(c)(3) 7 NA true WILCOX MEMORIAL HOSPITAL 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990074365 HOSPITAL HI 501(c)(3) 3 NA true HAWAI'I PACIFIC HEALTH 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990246363 HOLDING COMP HI 501(c)(3) 11b, III-FI NA false ASC PACIFIC VENTURES LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 270540034 AMBU. SURG. CNTR. AL NA HAWAII PACIFIC HEALTH PARTNERS INC & SUB 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990318588 HOLDING COMPANY HI NA C Corp HICORD INC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990251496 INVESTMENT HI NA C Corp STRAUB PHARMACY INC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990145107 INACTIVE HI NA C Corp false false true false false false false false false false false false false false true true true true true STRAUB CLINIC & HOSPITAL q 61387 FMV STRAUB CLINIC & HOSPITAL r 348038 FMV STRAUB CLINIC & HOSPITAL s 292246 FMV WILCOX MEMORIAL HOSPITAL q 1581252 FMV WILCOX MEMORIAL HOSPITAL r 55549 FMV KAPIOLANI WOMEN & CHILDREN q 52435 FMV PROVIDERS INSURANCE CORPORATION r 1921869 FMV SCHEDULE R, PART III ASC PACIFIC VENTURES, LLC EIN: 27-0540034 ADDRESS: 3000 RIVERCHASE GALLERIA, STE 500 BIRMINGHAM, AL 35244