2015-11-16T08:35:35-06:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 227 WEST TRADE STREET SUITE 800 CHARLOTTE NC 28202 990 2014-10-01 561853201 RANDOLPH MEDICAL ASSOCIATES RAND 3366255151 218C FOUST ST ASHEBORO NC 27203 ROBERT S CLAUSER PRESIDENT 3366255151 2015-11-12 1 JOHN NORMAN P01506766 7049985200 2014 2016-02-25 16:41:14Z X ROBERT S CLAUSER 218C FOUST ST ASHEBORO NC 27203 2360254 0 X WWW.RANDOLPHMEDICAL.ORG X 1993 NC THE MISSION OF RANDOLPH MEDICAL ASSOCIATES IS TO PROVIDE TIMELY, CONVENIENT ACCESS TO A BROAD RANGE OF QUALITY MEDICAL SERVICES. X 8 4 110 0 0 0 0 0 9611426 2360254 0 0 188393 0 9799819 2360254 0 0 0 0 6146659 1607332 0 0 0 2924122 853643 9070781 2460975 729038 -100721 1711233 0 3093033 0 -1381800 0 X THE MISSION OF RANDOLPH MEDICAL ASSOCIATES IS TO PROVIDE TIMELY, CONVENIENT ACCESS TO A BROAD RANGE OF QUALITY MEDICAL SERVICES. 0 1 2361705 2360254 DURING THE THREE MONTHS ENDING DECEMBER 31, 2014, RANDOLPH MEDICAL ASSOCIATES PROVIDED INTERNAL MEDICINE, FAMILY PRACTICE, AND PEDIATRIC SERVICES TO THE COMMUNITY. EFFECTIVE DECEMBER 31, 2014, THE ORGANIZATION MERGED INTO RANDOLPH SPECIALTY GROUP PRACTICE AND CEASED OPERATIONS. 2361705 1 0 0 0 0 0 0 0 0 0 0 0 0 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 1 0 0 1 0 0 0 1 52 0 1 110 1 0 0 0 0 0 0 0 0 0 0 X 8 4 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 X X LORETTA LONG 3363283443 216A FOUST STREET ASHEBORO NC 27203 MAC PUGH CHAIRMAN 0.50 2.00 X X 0 0 0 SAM RANKIN JR VICE CHAIRMAN 0.50 2.50 X X 0 0 0 STEVE EBLIN SECRETARY/TREASURER 0.50 40.00 X X 0 361940 58662 SAM CRANFORD JR DIRECTOR/EX-OFFICIO 0.50 5.50 X 0 0 0 BETH RUSSELL DIRECTOR 0.50 X 0 0 0 PATRICIA VINOCUR PHYSICIAN/BOARD DIRECTOR 40.00 0.50 X 259729 0 4453 ROBERT S CLAUSER PRESIDENT 0.50 40.00 X X 0 183961 25394 KEUNG W LEE PHYSICIAN/BOARD DIRECTOR 40.00 0.50 X 342947 0 8141 MURRAY S MARSH JR CFO - RHI 2.00 40.00 X 0 216596 25030 JOHN F GAGE PHYSICIAN 40.00 X 293428 0 2379 DOUGLAS E SCHULTZ PHYSICIAN 40.00 X 243476 0 9236 KATHLEEN RILEY PHYSICIAN 40.00 X 205104 0 8280 STEPHEN D CAMPBELL PHYSICIAN 40.00 X 195558 0 0 MAURA L HAMRICK PHYSICIAN 40.00 X 169089 0 8123 1709331 762497 149698 11 0 1 0 MISYS HEALTHCARE SYSTEMS LLC 24630 NETWORK PLACE CHICAGO IL 60673 SOFTWARE MAINTENANCE 297864 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 CONTRACT LABOR 185041 B&B CLEANING PO BOX 4640 ASHEBORO NC 27204 CLEANING SERVICES 153420 LABORATORY CORPORATION OF AMERICA HOLDIN PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 127555 4 PATIENT SERVICE REVENU 621300 2360254 2360254 2360254 2360254 2360254 0 0 1502261 1431570 70691 17763 16587 1176 87308 81528 5780 3099 3099 1767 1767 14395 14395 4716 4716 103066 86309 16757 18999 18999 184236 184236 7198 7198 669 669 42672 42672 10599 10599 MEDICAL SUPPLIES 442921 442921 MISCELLANEOUS 19306 19306 2460975 2361705 99270 0 75405 0 0 0 805424 0 0 0 0 221033 0 63814 0 0 0 501155 0 0 0 0 0 44402 0 1711233 0 824966 0 2268067 0 3093033 0 X -1381800 0 -1381800 0 1711233 0 X -100721 1482521 X X 0 1 X 1 0 X 7737614 7691618 8171918 9611426 2360254 35572830 7737614 7691618 8171918 9611426 2360254 35572830 0 0 0 35572830 225410 499283 454487 188393 1367573 7963024 8190901 8626405 9799819 2360254 36940403 0.96300 0.96570 0.00000 X SCHEDULE A, PART III THE SUPPORT TEST INCLUDES THE CURRENT YEAR, WHICH IS A SHORT PERIOD TAX YEAR FROM OCTOBER 1, 2014 THROUGH DECEMBER 31, 2014. 0 X PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. IT WAS DETERMINED THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF DECEMBER 31, 2014. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2011 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 0 1 0 0 0 0 0 0 0 STEVE EBLIN SECRETARY/TREASURER 0 344440 0 0 0 17500 0 52646 0 6016 0 420602 0 0 PATRICIA VINOCUR PHYSICIAN/BOARD DIRECTOR 202503 0 24188 0 33038 0 0 0 4453 0 264182 0 0 0 ROBERT S CLAUSER PRESIDENT 0 176692 0 0 0 7269 0 18120 0 7274 0 209355 0 0 KEUNG W LEE PHYSICIAN/BOARD DIRECTOR 276645 0 30914 0 35388 0 0 0 8141 0 351088 0 0 0 MURRAY S MARSH JR CFO - RHI 0 170596 0 0 0 46000 0 21098 0 3932 0 241626 0 0 JOHN F GAGE PHYSICIAN 249618 0 19104 0 24706 0 0 0 2379 0 295807 0 0 0 DOUGLAS E SCHULTZ PHYSICIAN 223568 0 0 0 19908 0 0 0 9236 0 252712 0 0 0 KATHLEEN RILEY PHYSICIAN 158723 0 45680 0 701 0 0 0 8280 0 213384 0 0 0 STEPHEN D CAMPBELL PHYSICIAN 148494 0 29872 0 17192 0 0 0 0 0 195558 0 0 0 MAURA L HAMRICK PHYSICIAN 127665 0 32784 0 8640 0 0 0 8123 0 177212 0 0 0 PART I, LINE 4B CERTAIN INDIVIDUALS PARTICIPATE IN A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN. A DESCRIPTION OF THIS PLAN IS LISTED BELOW. THE AMOUNTS REPRESENTED AS DEFERRED COMPENSATION ON SCHEDULE J HAVE NOT BEEN PAID TO THE INDIVIDUALS. THE NUMBER REPRESENTS VESTED BENEFITS WHICH MAY BE PAID IN FUTURE YEARS, DEPENDING ON THE INDIVIDUAL'S LIFE SPAN AND OTHER FACTORS WHICH COULD RESULT IN FORFEITURE OF THE BENEFIT. DURING 1998, RANDOLPH HOSPITAL (A RELATED ORGANIZATION) ESTABLISHED SUPPLEMENTAL PLANS TO COVER HIGHLY COMPENSATED EMPLOYEES. THESE PLANS INCLUDED A NONQUALIFIED SUPPLEMENTAL RETIREMENT PLAN, A DEFERRED COMPENSATION PLAN, AND A SPLIT-DOLLAR LIFE INSURANCE PLAN (WHICH IS ONLY OFFERED TO CERTAIN EXECUTIVES PAID BY RANDOLPH HOSPITAL). THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN PROVIDES ADDITIONAL BENEFITS TO SUPPLEMENT BENEFITS EARNED UNDER THE DEFINED BENEFIT PENSION PLAN. IN 2005, THE HOSPITAL INSTITUTED A NONQUALIFIED DEFERRED COMPENSATION PLAN. THE PURPOSE OF THIS PLAN IS TO PROVIDE ADDITIONAL RETENTION INCENTIVES AND RETIREMENT SECURITY FOR CERTAIN MEMBERS OF THE HOSPITAL'S SENIOR MANAGEMENT TEAM AND TO ALLOW FOR THE DEFERRAL OF COMPENSATION OF THOSE ELIGIBLE MEMBERS OF ITS SENIOR MANAGEMENT. THIS IS INTENDED TO BE A NONQUALIFIED PLAN. PARTICIPANTS ARE 100% VESTED AFTER 30 YEARS OF SERVICE OR AT AGE 67. ON OCTOBER 1, 2013, A NEW NON-QUALIFIED DEFERRED COMPENSATION PLAN WAS IMPLEMENTED WHICH REPLACED ALL PRIOR PLANS. MERGED WITH RANDOLPH SPECIALTY GROUP. 2015-01-01 1711233 113827203 1 0 0 0 1 1 1 1 0 PART I, LINE 2E: PERSON(S) INVOLVED: BOARD OF DIRECTORS PART I, LINE 2E: EXPLANATION OF INVOLVEMENT: THE BOARDS OF RANDOLPH MEDICAL ASSOCIATES, AND RANDOLPH SPECIALY GROUP MERGED. FORM 990, PART III, LINE 3 EFFECTIVE 12/31/14, RANDOLPH MEDICAL ASSOCIATES MERGED INTO RANDOLPH SPECIALTY GROUP PRACTICE, A RELATED NORTH CAROLINA NONPROFIT ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS RANDOLPH HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 7A DIRECTORS SHALL BE ELECTED BY THE AFFIRMATIVE VOTE OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER. ANY VACANCY OCCURING ON THE BOARD MAY BE FILLED BY THE AFFIRMATIVE VOTE OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER. A DIRECTOR ELECTED TO FILL A VACANCY SHALL BE ELECTED FOR THE UNEXPIRED TERM OF HIS PREDECESSOR IN OFFICE. FORM 990, PART VI, SECTION A, LINE 7B CERTAIN POWERS ARE RESERVED EXCLUSIVELY UNTO THE SOLE MEMBER OF THE ORGANIZATION, WHICH SHALL EXERCISE SUCH POWERS IN ACCORDANCE WITH LAW AND THE AFFIRMATIVE VOTE OF A MAJORITY OF THE MEMBERS OF ITS BOARD OF DIRECTORS, AS THEN CONSTITUTED, SUCH POWERS TO BE (1) TO MERGE OR CONSOLIDATE THE ORGANIZATION WITH ANY OTHER NONPROFIT CORPORATION, (2) TO ACQUIRE OR CREATE ANOTHER CORPORATION, (3) TO MAKE A CAPITAL EXPENDITURE OVER A SPECIFIED DOLLAR LIMIT TO BE ESTABLISHED FROM TIME TO TIME BY THE SOLE MEMBER, (4) TO SELL CAPITAL ASSETS VALUED OVER A SPECIFIED DOLLAR LIMIT TO BE ESTABLISHED FROM TIME TO TIME BY THE SOLE MEMBER, (5) TO APPROVE ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BY LAWS PROPOSED BY THE ORGANIZATION, (6) PERMISSION TO DISSOLVE THE ORGANIZATION, AND (7) TO APPOINT THE MEMBERS OF THE ORGANIZATION'S BOARD OF DIRECTORS AS PROVIDED IN ARTICLE III, SECTION 2 AND 4 OF THE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 THE 990, ALONG WITH A SUMMARY OF KEY ELEMENTS AND DISCLOSURES, IS PROVIDED TO THE BOARD INVITING QUESTIONS AND COMMENTS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION SHARES WITH RANDOLPH HOSPITAL A PART TIME CORPORATE COMPLIANCE OFFICER CHARGED WITH EDUCATING THE BOARD, OFFICERS AND OTHER EMPLOYEES ON THE CONFLICT OF INTEREST POLICY. ALL NEW EMPLOYEES ARE GIVEN INFORMATION UPON ORIENTATION, AND CURRENT EMPLOYEES ARE REQUIRED TO TAKE ANNUAL EDUCATION ON COMPLIANCE WITH THE POLICY. REGULARLY SCHEDULED CORPORATE COMPLIANCE MEETINGS TO UPDATE KEY INDIVIDUALS ON NEW ISSUES AND NEW INFORMATION REGARDING CORPORATE COMPLIANCE. BOARD OF DIRECTORS ARE REQUIRED TO ANNUALLY READ, SIGN AND REMIT COPY OF THE POLICY TO THE BOARD CHAIR IN REGARDS TO THE CONFLICT OF INTEREST POLICY. ALL BOARD MEMBERS ARE AWARE OF POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSLEVES FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION COMMITTEE OF THE BOARD ENGAGED AN EXTERNAL CONSULTANT TO ASSIST WITH NOT ONLY THE CEO'S COMPENSATION, BUT THE VICE PRESIDENTS' COMPENSATION, AS WELL. THE EXTERNAL CONSULTANT USED THEIR MARKET DATABASE TO PROVIDE THE COMPENSATION COMMITTEE WITH SALARIES AT THE 25TH, 50TH, AND 75TH PERCENTILES FOR SIMILAR SIZED ORGANIZATIONS. ALL BASE SALARIES ARE APPROXIMATELY AT THE 30TH PERCENTILE. A PORTION OF EXECUTIVE SALARIES ARE AT RISK THROUGH AN INCENTIVE PROGRAM TIED TO ANNUAL GOALS. SHOULD ALL OF THE GOALS BE ACHIEVED IN A GIVEN YEAR, TOTAL COMPENSATION FOR EXECUTIVE LEADERS GOES TO APPROXIMATELY THE 50TH PERCENTILE. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. FORM 990, PART XI, LINE 9: ADJUSTMENT DUE TO DISSOLUTION OF ENTITY 1,482,521. FORM 990, PART XII, LINE 2C: THE PROCESS HAD NOT CHANGED SINCE PRIOR YEAR. RANDOLPH HOSPITAL INC PO BOX 1048 ASHEBORO NC 27204 560530234 HEALTHCARE NC 501(C)(3) LINE 3 N/A 0 RANDOLPH SPECIALTY GROUP 364 WHITE OAK STREET ASHEBORO NC 27204 113827203 HEALTHCARE NC 501(C)(3) LINE 9 RANDOLPH HOSPITAL INC 0 RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION 346 WHITE OAK STREET ASHEBORO NC 27204 582240755 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I RANDOLPH HOSPITAL INC 0 STAYWELL SENIOR CENTER PO BOX 1048 ASHEBORO NC 27204 461289922 HEALTHCARE NC 501(C)(3) LINE 3 RANDOLPH HOSPITAL INC 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 RANDOLPH HOSPITAL K 20310 COST RANDOLPH HOSPITAL S 267053 CASH RANDOLPH SPECIALTY GROUP R 255000 COST RANDOLPH HOSPITAL Q 142258 COST