2016-11-14T17:40:53-06:00 2015-12-31 910189318 Moss Adams LLP 101 Second Street Suite 900 San Francisco CA 94105 990 2015-01-01 271376321 Prima Medical Foundation PRIM 4158425000 9 Commercial Blvd No 200 Novato CA 94949 Robert Newbury MD CEO 4158425000 2016-11-09 1 Renie Burbank P00159653 4159561500 2015 2017-02-10 21:41:12Z Robert Newbury MD 9 Commercial Blvd No 200 Novato CA 94949 41044165 0 X WWW.PRIMAMEDGROUP.COM X 2010 CA To provide the recruitment and retention of physicians, become the model of choice for physicians, improve clinical quality, patient access and enhance on-going stability and financial viability for physicians and their sponsors. 11 7 177 7 0 0 10375698 10764328 29099200 30101848 0 7293 165001 144812 39639899 41018281 0 0 0 0 9836703 10519488 0 0 0 29231177 29928214 39067880 40447702 572019 570579 13775096 9707341 11702462 7064128 2072634 2643213 X To provide the recruitment and retention of physicians, become the model of choice for physicians, improve clinical quality, patient access and enhance on-going stability and financial viability for physicians and their sponsors. 0 0 13481125 10959144 PRIMARY CARE PROGRAM PROVIDES MARIN & SONOMA COUNTY COMMUNITY WITH PRIMARY CARE SERVICES FOR ADULTS & CHILDREN IN NOVATO, SAUSALITO, PRIMA KIDS IN MILL VALLEY, SONOMA, TAMALPAIS & TERRA LINDA. 8268787 6738489 OBGYN Program provides OBGYN Services including Labor & Delivery to Marin & Sonoma Counties as well as provides physician & CNM hospitalists call coverage for Marin General Hospital and Sonoma Valley Hospital. 11534242 12404215 See Schedule OPrima Medical Foundation provides surgical services for Marin & Sonoma Counties in the areas of General surgery, Orthopedics, and Breast Oncology. In addition, the COmpany provides intesivist services and offers a pediatric after hours clinic and hospitalist call coverage.PMF is a nonprofit public benefit corporation which provides medical services pursuant to a Professional Services Agreement with the Prima Medical Group, Inc., a California professional medical corporation. PMF provides these medical services to both insured and uninsured residents located primarily in Marin and Sonoma counties in California. These services are provided at twelve outpatient clinics that it owns and operates and at three local hospitals. The medical services encompass multiple specialties including: Internal Medicine, Family Medicine, General Practice, Geriatrics, Pediatrics, Obstetrics, Gynecology, Infectious Disease, General Surgery, Colorectal Surgery, Breast Surgery, Bariatrics, Orthopedics, Dermatology, Pulmonary Medicine, and Critical Care. These services are funded by patient, insurance and other third party billings and by collections, contributions and loans from local hospitals. Patients are served without limitation based on their ability to pay, provided they are residents of Marin or Sonoma counties. 33284154 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 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 1 0 0 0 1 55 0 1 177 1 0 0 0 0 0 0 0 0 0 0 X 11 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 CA X James P McManus 4158425000 9 Commercial Blvd Ste 200 Novato CA 94949 X LEE DOMANICO CHAIRMAN/MGH CEO 1.00 39.00 X X 0 1568309 17885 STEVE SCHROEDER VICE CHAIRMAN 1.00 2.00 X X 0 0 0 GENE O'CONNELL SECRETARY 1.00 2.00 X X 0 0 0 JEREMY FAIR TREASURER 1.00 2.00 X X 0 0 0 JOEL CRISTE Board Member/MMN CEO (thru 8/2015) 1.00 39.00 X 0 0 0 JON FRIEDENBERG BOARD MEMBER 1.00 39.00 X 0 625180 47642 JOSEPH HABIS MD BOARD MEMBER 1.00 39.00 X 0 0 0 PAUL KIRINCIC BOARD MEMBER 1.00 2.00 X 0 0 0 KELLY MATHER BOARD MEMBER 1.00 0.00 X 0 0 0 MARK ZIELAZINSKI BOARD MEMBER 1.00 39.00 X 0 445481 35285 ROBERT NEWBURY MD Chief Executive Officer 39.00 1.00 X X 75000 0 0 WAYNE FAIRCHILD CEO (Thru 10/2015) 40.00 0.00 X 269305 0 21791 CHERI HAWKINS CFO (Thru 12/2015) 40.00 0.00 X 163796 0 26716 ALFREDO LIMJOCO DIR OF IT (Thru 12/16/2016) 40.00 0.00 X 165227 0 6241 LINDA CHOTKEVYS DIR OF HUMAN RESOURCES 40.00 0.00 X 154783 0 27305 SHERI MATTEO DIRECTOR OF MIDWIFERY 40.00 0.00 X 138683 0 19658 RANDALL ICHIHANA PULMONARY SERVICES MANAGER 40.00 0.00 X 120711 0 9142 JODY BRANHAM CERTIFIED NURSE MIDWIFE 40.00 0.00 X 106699 0 25506 1194204 2638970 237171 9 0 1 0 Jones Day 555 California Street 26th Floor San Francisco CA 94104 Legal SERVICES 334469 Moss Adams LLP PO Box 748369 Los Angeles CA 900748369 ACCOUNTING SERVICES 144780 MERRI MARTORI NP 34 WATERBURY LANE NOVATO CA 94949 NURSE PRACTIONER 111381 3 10151648 162680 450000 10764328 NET PATIENT SERVICES 621400 23981800 23981800 OTHER HMO REVENUE 621400 4940643 4940643 CAPITATION PREMIUM 621400 1179405 1179405 30101848 144812 0 144812 144812 144812 33177 25884 7293 7293 7293 41018281 30101848 0 152105 556607 556607 7139374 4715981 2423393 128996 84416 44580 2046210 1555287 490923 648301 467917 180384 20822120 19210040 1612080 100066 100066 172305 172305 343414 343414 46690 46690 1527628 1081677 445951 177446 177446 2535123 2325572 209551 32980 32980 66092 66092 92373 92373 980848 544820 436028 1005657 978053 27604 drugs AND IMMUNIZATIONS 1748544 1748544 Triage service 157760 157760 119168 90879 28289 40447702 33284154 7163548 0 293991 240527 3146039 3148810 227679 415862 738874 664934 6628675 3772302 3668467 2856373 5700046 2380835 13775096 9707341 2036596 2157064 2000000 2000000 7665866 2907064 11702462 7064128 X 2072634 2643213 2072634 2643213 13775096 9707341 570579 0 X 0 1 X 1 0 X 3522954 6581810 11202923 10375698 10764328 42447713 23396678 27435521 29176179 29099200 30101848 139209426 26919632 34017331 40379102 39474898 40866176 181657139 0 0 0 181657139 165001 144812 309813 165001 144812 309813 26919632 34017331 40379102 39639899 41010988 181966952 0.99830 0.00170 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2454299 1531420 922879 1559105 872272 686833 2615271 1368610 1246661 2856373 RELATED PARTY RECEIVABLEs 2380835 2380835 Payable to Prima Medical Group 880377 RELATED PARTY PAYABLES 175206 DEFERRED RENT LIABILITY 967442 Insurance CLAIMS Payable 374000 Lease Payable 510039 2907064 X 41018281 0 41018281 0 41018281 40447702 0 40447702 0 40447702 Part X, Line 2: PRIMA MEDICAL FOUNDATION ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH ASC 740. ASC 740 CLARIFIES THE ACCOUNTING FOR INCOME TAXES BY PRESENTING A MINIMUM PROBABILITY THRESHOLD THAT A TAX POSITION MUST MEET BEFORE A FINANCIAL STATEMENT BENEFIT IS RECOGNIZED. THE MINIMUM THRESHOLD IS DEFINED BY ASC 740 AS A TAX POSITION THAT IS MORE LIKELY THAN NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPLICABLE TAXING AUTHORITY, INCLUDING RESOLUTION OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT TO BE RECOGNIZED IS MEASURED AS THE LARGEST AMOUNT OF BENEFIT THAT IS GREATER THAN FIFTY PERCENT OF BEING REALIZED UPON ULTIMATE SETTLEMENT. AT DECEMBER 31, 2015 AND 2014, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. X X X 1 0 0 0 0 0 0 1 0 LEE DOMANICO CHAIRMAN/MGH CEO 0 774366 0 793943 0 0 0 17885 0 0 0 1586194 0 0 JON FRIEDENBERG BOARD MEMBER 0 402126 0 223054 0 0 0 17726 0 29916 0 672822 0 0 MARK ZIELAZINSKI BOARD MEMBER 0 330281 0 70116 0 45084 0 14047 0 21238 0 480766 0 0 WAYNE FAIRCHILD CEO (Thru 10/2015) 209478 0 0 0 59827 0 0 0 21791 0 291096 0 0 0 CHERI HAWKINS CFO (Thru 12/2015) 163796 0 0 0 0 0 2517 0 24199 0 190512 0 0 0 ALFREDO LIMJOCO DIR OF IT (Thru 12/16/2016) 165227 0 0 0 0 0 4388 0 1853 0 171468 0 0 0 LINDA CHOTKEVYS DIR OF HUMAN RESOURCES 154783 0 0 0 0 0 1799 0 25506 0 182088 0 0 0 SHERI MATTEO DIRECTOR OF MIDWIFERY 138683 0 0 0 0 0 4209 0 15449 0 158341 0 0 0 Part I, Line 3, Other reportable Compensation The taxable compensation received by the executive team included benefits such as health and welfare disability, long-term care insurance and life insurance. The other reportable compensation was included in their form W-2. Part I, Line 4a Wayne Fairchild received a Severance payment OF $59,827. THE AMOUNT WAS INCLUDED IN HIS FORM W-2. Part I, Line 6 The calculation of bonuses is dependent on many factors that are assigned various weightings. Those factors are: - Patient satisfaction survey scores - Employee satisfaction survey scores - Physician satisfaction survey scores - Excess of revenue over expenses - Revenue growth - Community benefit programs - Quality and safety results Form 990, Part VI, Section A, line 3 EFFECTIVE OCTOBER 1, 2015, DR. ROBERT NEWBURY WAS APPOINTED CEO OF PRIMA MEDICAL FOUNDATION. Form 990, Part VI, Section B, line 11 PRIMA MEDICAL FOUNDATION'S FORM 990 IS REVIEWED BY THE CONTROLLER AND THE CEO OR COO. An electronic copy is sent to the board of directors prior to filing with the internal revenue service. Form 990, Part VI, Section B, line 12c The organization's conflict of interest policy applies to officers, directors and immediate family members and requires disclosures to the Board of any financial interests in a proposed transaction or agreement. If the Board determines that the financial interest is a conflict of interest, the interested director will not be a voting member on the issue in question. The policy requires an annual distribution to officers and directors as well as periodic reviews as needed. Form 990, Part VI, Section B, line 15 The CEO and CFO's compensation are set by the Foundation's board through negotiation regarding complete listing of duties and agreement to accomplish certain goals. Comparability data was used to the extent that it was available and a written contract was signed. Other key employees in PMF are generally hired through recruiting agencies. Salary is established at market rates represented in the region by job title and description of duties to be accomplished. These are compared with other salary surveys and publications such as MGMA. Form 990, Part VI, Section C, line 19 Prima Medical Foundation makes this information readily available for public inspection during regular business hours at their principal office. 990, PART VII Lee Domanico, CEO of MGH, Jon Friedenberg, CAO of MGH, and Mark Zielazinski, CITIO of MGH are listed as members of the board of Prima Medical Foundation. They are employed and compensated by Marin General Hospital (MGH), a related organization. MGH reports 100% of the individual's compensation on W-2's which are issued by MGH. They devoted an average of one hour per week relating to their duties associated with serving on the Board of Directors. The reportable compensation is related to their services provided to Marin General Hospital and is unrelated to the average number of hours per week for their duties as a board member. MARIN GENERAL HOSPITAL 250 bon air road GREENBRAE CA 94904 942823538 Hospital CA 501(C)(3) 3 MARIN GENERAL HOSPITAL 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0