2015-05-13T06:03:23-05:00 2014-06-30 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2013-07-01 611508839 Alliance Health 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 14953001 0 0928 X www.catholicmedicalcenter.org X 2007 NH To promote health care programs from the greater Manchester, New Hampshire community. 8 4 0 5 0 0 0 0 15262417 14953001 0 0 0 0 15262417 14953001 0 0 0 0 0 0 0 0 0 19126505 19147058 19126505 19147058 -3864088 -4194057 2900233 3770676 1641846 3156346 1258387 614330 To promote health care programs for a broad cross-section of the greater Manchester, New Hampshire community. 0 0 16289317 14953001 To promote health care programs for a broad cross-section of the greater Manchester, New Hampshire community. 16289317 1 0 0 0 0 0 0 0 0 0 1 0 0 0 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 0 0 0 1 3 0 1 0 0 0 0 0 0 0 0 0 0 0 X 8 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Edward L Dudley III 6036683545 100 McGregor St Manchester NH 03102 William B Clutterbuck MD Director 1.00 43.00 X 0 352749 36460 Raef Fahmy DPM Director 1.00 42.00 X 0 255376 16062 Stephen J Leblanc Director 1.00 X 0 0 0 Steven Paris MD Director 1.00 X 0 0 0 Maria C Mongan Chair 1.00 3.00 X X 0 0 0 Joseph Graham Chair (Part Year) 1.00 4.00 X X 0 0 0 Suzanne Mellon PhD RN Vice Chair 1.00 3.00 X X 0 0 0 Joseph Pepe MD President & CEO 1.00 44.00 X X 0 615990 114075 Edward Dudley III Treasurer/Secretary 1.00 43.00 X X 0 432406 92784 Alyson Pitman Giles Former Officer 0.00 X 0 333381 5250 0 1989902 264631 0 1 1 0 Dartmouth Hitchcock Clinic One Medical Center Dr Lebanon NH 03756 Physician Services 16094056 1 Patient Service Rev. 621400 14119798 14119798 Rental Income 532000 602035 602035 Miscellaneous Revenue 621400 231168 231168 14953001 14953001 14953001 0 0 X 2857741 2857741 13080741 13080741 40773 40773 1856033 1856033 3676 3676 54926 54926 Bad Debts 567058 567058 Medical & Pharmaceutica 457936 457936 Transcription 146178 146178 Equipment Rental 64774 64774 17222 17222 19147058 16289317 2857741 0 348749 1343831 2112124 2039094 80588 83906 662737 358892 358772 303845 2900233 3770676 1606373 3141014 35473 15332 1641846 3156346 X 1258387 614330 1258387 614330 2900233 3770676 X -4194057 3550000 X X 0 1 X 1 0 X X X 0 0 0 Catholic Medical Ctr 020315693 3 1 0 1 0 Schedule A, Part I, Line 11h: Alliance Health Services supports its affiliated tax-exempt organization by providing supplemental health care services to Hospital patients. The monetary value of this support cannot be accurately estimated. 662737 358892 303845 303845 Due to Affiliates 15332 15332 X 14953001 0 14953001 0 14953001 19147058 0 19147058 0 19147058 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 Joseph Pepe MD President & CEO 0 450939 0 115704 0 49347 0 94306 0 19769 0 730065 0 0 Edward Dudley III Treasurer/Secretary 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: $75,456 Edward Dudley, III: $46,313 Form 990, Part VI, Section A, line 6 The sole member of Alliance Health Services is Catholic Medical Center Form 990, Part VI, Section A, line 7a The directors are appointed by the sole member. Form 990, Part VI, Section A, line 7b The sole member has reserved powers over Alliance Health Services but does not approve each separate action taken by the 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 and directors are required to complete a conflict of interest questionnaire 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 governing documents, the conflict of interest policy, and the financial statements are available upon request. Form 990, Part IX, line 11g Physician Fees: Program service expenses 13,080,741. Management and general expenses 0. Fundraising expenses 0. Total expenses 13,080,741. Form 990, Part XI, line 9: Transfer From Affiliates 3,550,000. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. CMC Ancillary Health Services LLC 100 McGreggor Street Manchester NH 03102 464389318 Ancillary Health Services NH 0 0 Catholic Medical Center 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 Peter's Home 100 Mcgregor Street Manchester NH 03102 020222228 Home NH 501(c)(3) Line 9 CMC Healthcare System 0 Alliance Ambulatory Services 100 Mcgregor Street Manchester NH 03102 020519436 Ambulatory Surgical Center NH 501(c)(3) Line 11b, II 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 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 Alliance Enterprises 100 McGregor Street Manchester NH 03102 020386795 Real Estate NH N/A C 0 Doctors' Medical Association 100 McGregor Street Manchester NH 03102 020340690 Medical Office Building NH N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1