2015-05-13T06:03:23-05:00 2014-06-30 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2013-07-01 020519436 Alliance Ambulatory Services ALLI 6036683545 100 McGregor Street Manchester NH 03102 Edward L Dudley III Exec VP & CFO 6036683545 2015-05-06 Nicholas E Porto P01310283 2078792100 2013 2016-03-07 17:11:31Z Joseph Pepe MD 100 McGregor Street Manchester NH 03102 2580528 0 0928 X www.catholicmedicalcenter.org X 2000 NH To promote and generate healthcare programs for a broad cross-section of the greater Manchester, New Hampshire community. 20 14 0 14 0 0 0 0 2266573 2580501 83 27 0 0 2266656 2580528 0 0 0 0 0 0 0 0 0 0 0 0 0 2266656 2580528 6176712 6272240 915 915 6175797 6271325 To create and promote healthcare programs in the Manchester, New Hampshire community. 0 0 2580501 Revenue from partnership interest in Bedford Ambulatory Surgical Center, LLC 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 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 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 20 14 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 NH X Edward L Dudley III 6036683545 100 McGregor Street Manchester NH 03102 Adele Boufford Baker Director 1.00 3.00 X 0 0 0 Gary Bouchard PhD Director (Part Year) 1.00 2.00 X 0 0 0 Guy D Chapdelaine Director (Part Year) 1.00 3.00 X 0 0 0 William B Clutterbuck MD Director 1.00 43.00 X 0 352749 36460 Eleanor Wm Dahar Esq Director 1.00 2.00 X 0 0 0 Raef Fahmy DPM Director 1.00 42.00 X 0 255376 16062 Joseph Graham Director 1.00 4.00 X 0 0 0 Connor J Haugh MD FACC Director 1.00 42.00 X 0 602513 38011 Powen Hsu MD Director 1.00 3.00 X 0 0 0 Susan D Huard PhD Director 1.00 2.00 X 0 0 0 Neil Levesque Director 1.00 3.00 X 0 0 0 Patrick A Mahon MD Director 1.00 42.00 X 0 438625 36674 Diane Murphy Quinlan Esq Director 1.00 3.00 X 0 0 0 Msgr John P Quinn Director 1.00 3.00 X 0 0 0 Keith A Stahl MD Director 1.00 3.00 X 0 295743 37938 Fr Patrick Sullivan OSB RN Director 1.00 3.00 X 0 0 0 Richard E Ashooh Director 1.00 3.00 X 0 0 0 Rick Botnick Chair 1.00 2.00 X X 0 0 0 Maria C Mongan Vice Chair 1.00 3.00 X X 0 0 0 Suzanne Mellon PhD RN Vice Chair (Part Year) 1.00 3.00 X X 0 0 0 Daryl J Cady CPA Treasurer 1.00 3.00 X X 0 0 0 John G Cronin Esq Secretary 1.00 2.00 X X 0 0 0 Margaret-Ann Moran Esq Secretary (Part Year) 1.00 4.00 X X 0 0 0 Joseph Pepe MD President & CEO 1.00 44.00 X X 0 615990 114075 Edward Dudley III Exec. VP & CFO 1.00 43.00 X 0 432406 92784 Alyson Pitman Giles Former Officer 0.00 X 0 333381 5250 0 3326783 377254 0 1 1 0 0 Interest in Ambulatory 621990 2580501 2580501 2580501 27 27 2580528 2580501 0 27 0 0 0 0 282222 477249 5894490 5794991 6176712 6272240 915 915 915 915 X 6175797 6271325 6175797 6271325 6176712 6272240 X 2580528 -2485000 X X 0 1 X 1 0 X X X 0 0 0 Catholic Medical Ctr 020315693 3 1 2485000 1 2485000 Schedule A, Part I, Line 11h: Alliance Ambulatory Services supports its affiliated tax-exempt organization by helping to create and promote healthcare programs in the Manchester, New Hampshire community. The monetary value of this support cannot be accurately estimated. 0 Investment in Bedford Ambulatory Surgical Care 5794991 F 5794991 X 2580528 0 2580528 0 2580528 0 0 0 0 0 Part X, Line 2: The System and all related entities, with the exception of Enterprises, are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the System's tax positions and concluded the System has maintained its tax-exempt status, does not have any significant unrelated business income, and had taken no uncertain tax positions that require adjustment to the consolidated financial statements. With few exceptions, the System is no longer subject to income tax examination by the U.S. federal or state tax authorities for years before 2011. 1 1 0 0 0 0 0 0 0 William B Clutterbuck MD Director 0 351042 0 1707 0 0 0 15300 0 21160 0 389209 0 0 Raef Fahmy DPM Director 0 250016 0 0 0 5360 0 14712 0 1350 0 271438 0 0 Connor J Haugh MD FACC Director 0 443242 0 121771 0 37500 0 17850 0 20161 0 640524 0 0 Patrick A Mahon MD Director 0 374137 0 24488 0 40000 0 15300 0 21374 0 475299 0 0 Keith A Stahl MD Director 0 213243 0 82500 0 0 0 17597 0 20341 0 333681 0 0 Joseph Pepe MD President & CEO 0 450939 0 115704 0 49347 0 94306 0 19769 0 730065 0 0 Edward Dudley III Exec. VP & CFO 0 307182 0 61805 0 63419 0 61613 0 31171 0 525190 0 0 Alyson Pitman Giles Former Officer 0 0 0 0 0 333381 0 0 0 5250 0 338631 0 0 Part I, Line 3 The Organization's President and CEO's compensation was established by a related organization, Catholic Medical Center. That organization used a compensation committee, independent compensation consultant, the Form 990 of other organizations, a compensation study/survey, and approval by their board of directors/compensation committee to determine the President and CEO's compensation and benefits. Part I, Lines 4a-b 4A: The following individual received base compensation under a severance agreement from a related organization (Catholic Medical Center). Alyson Pitman Giles: $326,435 4B: The following individuals take part in a section 457(f) forfeitable nonqualified deferred compensation plan through Catholic Medical Center (a related organization). The following represents contributions for many years of service. Joseph Pepe: $76,456 Edward Dudley, III: $46,313 Form 990, Part VI, Section A, line 6 The sole member of Alliance Ambulatory services is CMC Healthcare System. Form 990, Part VI, Section A, line 7a The directors of Alliance Ambulatory Services are appointed by the sole member. Form 990, Part VI, Section A, line 7b The sole member has reserved powers over Alliance Ambulatory Services but does not approve each separate action taken by the Alliance Ambulatory Services board. Form 990, Part VI, Section B, line 11 Form 990 is prepared by an independent tax accounting firm (Baker, Newman, Noyes). Upon completion, a draft of the Form 990 is sent to the Organization, where the CFO, Controller, and Director of Accounting perform a final in-house review prior to submission to the Board of Directors for final approval. Upon approval from Board, Form 990 is filed with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c Officers are required to complete a conflict of interest policy annually. Form 990, Part VI, Section B, line 15 A related organization, Catholic Medical Center utilizes a compensation committee of the board of directors to set compensation levels and determine bonus potential for its senior leadership team. The committee is assisted by an independent consultant who surveys like-sized and performing institutions to benchmark relevant salary scales for each position. The consultant's findings are presented to the compensation committee who considers that external data with actual performance against a list of pre-established goals per senior leaders to set prospective compensation levels and bonus values. Bonus amounts are determined by how well an executive achieves a pre-defined set of goals. These goals, in general, are tied to the achievement of a specific task or project. Some goals are attached to achieve overall financial performance and mission performance, not solely revenue generation. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part XI, line 9: Net Transfer to Affiliates -2,485,000. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Form 990, Part VI, Line 16b: The Organization currently does not have a written joint venture policy to evaluate its participation in joint ventures. However, the Organization does actively and consistently monitor its involvement with its joint ventures to safeguard and ensure the Organization's exempt status is not jeopardized with respect to such arrangements. The Catholic Medical Center System is currently examining all of its policies and is in the process of developing a written joint venture policy in the near future. CMC Ancillary Health Services LLC 100 McGregor Street Manchester NH 03102 464389318 Ancillary Health Services NH 0 0 Catholic Medical Center Alliance Health Services 100 McGregor Street Manchester NH 03102 611508839 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 Catholic Medical Center 100 McGregor Street Manchester NH 03102 020315693 Hospital NH 501(c)(3) Line 3 CMC Healthcare System 0 CMC Healthcare System 100 McGregor Street Manchester NH 03102 010568516 Parent NH 501(c)(3) Line 11b, II N/A 0 CMC Associates 100 McGregor Street Manchester NH 03102 020344786 Gift Shop NH 501(c)(3) Line 11b, II Catholic Medical Center 0 CMC Physician Practice Associates 100 McGregor Street Manchester NH 03102 020460245 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 St Peters Home 100 McGregor Street Manchester NH 03102 020222228 Home NH 501(c)(3) Line 9 CMC Healthcare System 0 Alliance Resources 100 McGregor Street Manchester NH 03102 020398138 Real Estate NH 501(c)(3) Line 11b, II CMC Healthcare System 0 McGregor Steet MOB LLC 100 McGregor Street Manchester NH 03102 134347316 Medical Office Building NH N/A Bedford Ambulatory Surgical Center LLC 11 Washington Place Bedford NH 03110 020519727 Surgical Center NH N/A Related 2619137 2584949 0 1 0.50000 Doctors' Medical Association 100 McGregor Street Manchester NH 03102 020340690 Medical Office Building NH N/A C 0 Alliance Enterprises 100 McGregor Street Manchester NH 03102 020386795 Real Estate NH N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0