2014-08-14T13:22:05-05:00 2013-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2012-10-01 561853201 RANDOLPH MEDICAL ASSOCIATES RAND 3366255151 218C FOUST ST ASHEBORO NC 27203 ROBERT S CLAUSER 3366255151 2014-08-14 1 JOHN NORMAN P01506766 7049985200 2012 2015-11-30 17:44:51Z ROBERT S CLAUSER 218C FOUST ST ASHEBORO NC 27203 8626405 0 X WWW.RANDOLPHMEDICAL.ORG X 1993 NC PROVISION OF PRIMARY CARE MEDICAL SERVICES IN RANDOLPH COUNTY, NC 7 4 96 0 0 0 0 0 7691618 8171918 0 0 499283 454487 8190901 8626405 0 0 0 0 5926435 6175423 0 0 0 2062431 2271833 7988866 8447256 202035 179149 1953121 1648811 4243108 3759649 -2289987 -2110838 X THE MISSION OF RANDOLPH MEDICAL ASSOCIATES IS TO PROVIDE TIMELY, CONVENIENT ACCESS TO A BROAD RANGE OF QUALITY MEDICAL SERVICES. 0 0 8021924 8171918 RANDOLPH MEDICAL ASSOCIATES PROVIDES INTERNAL MEDICINE, FAMILY PRACTICE, AND PEDIATRIC SERVICES TO THE COMMUNITY. RANDOLPH MEDICAL ASSOCIATES INTERNAL MEDICINE IS DEDICATED TO THE DIAGNOSIS AND MEDICAL TREATMENT OF ADULT AND GERIATRIC PATIENTS. OUR PHYSICIANS SPECIALIZE IN INTERNAL MEDICINE AND ARE REFERRED TO AS INTERNISTS. OUR INTERNISTS ARE ESPECIALLY SKILLED IN THE MANAGEMENT OF PATIENTS WHO HAVE UNDIFFERENTIATED OR MULTI-SYSTEM DISEASE PROCESSES. SINCE INTERNAL MEDICINE PATIENTS ARE OFTEN SERIOUSLY ILL OR REQUIRE COMPLEX INVESTIGATIONS, INTERNISTS PLAY A MAJOR ROLE IN DISEASE MANAGEMENT. SEE SCHEDULE O FOR CONTINUATION RANDOLPH MEDICAL ASSOCIATES FAMILY PRACTICE SPECIALIZE IN FAMILY MEDICINE PROVIDING COMPREHENSIVE CARE TO PATIENTS OF ALL AGES. THEY FOCUS ON THE PATIENT AS A WHOLE AND PROVIDE TREATMENT OVER LONG PERIODS OF TIME. OUR PHYSICIANS PROVIDE PREVENTIVE CARE AND MANAGE CHRONIC AND COMPLEX CONDITIONS. FAMILY PHYSICIANS TREAT A WIDE RANGE OF MEDICAL ISSUES AND COORDINATE CARE WITH OTHER MEDICAL PROVIDERS. WE STRIVE TO BUILD LONG-TERM RELATIONSHIPS TO PROVIDE INFORMATION AND TECHNIQUES TO HELP OUR PATIENTS TAKE CONTROL OF THEIR HEALTH INCLUDING MENTAL AND EMOTIONAL WELL BEING. OUR PHYSICIANS ARE TRAINED TO TREAT CHRONIC CONDITIONS, SUCH AS DIABETES AND HEART DISEASE, AS WELL AS ACUTE AILMENTS, SUCH AS FLU OR INFECTION. THEY ALSO SCREEN FOR EARLY SIGNS OF SERIOUS CONDITIONS, SUCH AS CANCER.RANDOLPH MEDICAL ASSOCIATES PEDIATRIC IS DEDICATED TO THE HEALTH OF INFANTS, CHILDREN, AND ADOLESCENTS, THEIR GROWTH AND DEVELOPMENT AND THEIR OPPORTUNITY TO ACHIEVE FULL POTENTIAL AS ADULTS. OUR PEDIATRICIANS PROVIDE MEDICAL CARE FOR CHILDREN WHO ARE ACUTELY OR CHRONICALLY ILL AND ALSO PREVENTIVE HEALTH SERVICES FOR HEALTHY CHILDREN. OUR PEDIATRICIANS MANAGE THE PHYSICAL, MENTAL, AND EMOTIONAL WELL-BEING OF THE CHILDREN UNDER THEIR CARE AT EVERY STAGE OF DEVELOPMENT, IN BOTH SICKNESS AND HEALTH. OUR PEDIATRICIANS COLLABORATE WITH OTHER SPECIALISTS TO ENSURE QUALITY HEALTH CARE. 8021924 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 51 0 1 96 1 0 0 0 0 0 0 0 0 0 0 X 7 4 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 NC X X LORETTA LONG 3363283443 216A FOUST STREET ASHEBORO NC 27203 X MAC PUGH 2.00 X X 0 0 0 SAM RANKIN JR 2.00 X X 0 0 0 STEVE ELBIN 2.00 38.00 X X 0 280374 4505 SAM CRANFORD JR 2.00 X 0 0 0 BETH RUSSELL 2.00 X 0 0 0 PATRICIA VINOCUR 40.00 X 211261 0 5610 ROBERT S CLAUSER 2.00 38.00 X X 82805 100608 6229 MURRAY S MARSH JR 2.00 38.00 X 0 56975 982 KEUNG W LEE 40.00 X 337582 0 11574 JOHN F GAGE 40.00 X 303268 0 3716 DOUGLAS E SCHULTZ 40.00 X 273005 0 6961 KATHLEEN RILEY 40.00 X 181048 0 9126 1388969 437957 48703 5 0 1 0 PHYSICIAN SALES & SERVICE INC PO BOX 741378 ATLANTA GA 30374 DRUG EXPENSE/PATIENT SUPPLIES 367140 MISYS HEALTHCARE SYSTEMS LLC 24630 NETWORK PLACE CHICAGO IL 60673 SOFTWARE MAINTENANCE 297848 QUEST DIAGNOSTICS INC PO BOX 740736 ATLANTA GA 30374 LAB WORK 112576 3 PATIENT SERVICE REVENU 621300 8171918 8171918 8171918 OTHER REVENUE 900099 400489 400489 AFFILIATE MGMT 900099 53998 53998 454487 8626405 8171918 0 454487 328151 328151 4838393 4838393 679688 634693 44995 329191 307399 21792 2634 2634 169 169 7238 7238 266114 266114 17143 17143 141380 118393 22987 43512 43512 711989 711989 19902 19902 3234 3234 130563 130563 54090 54090 MEDICAL SUPPLIES 795317 795317 BAD DEBTS 49321 49321 MISCELLANEOUS 29227 29227 8447256 8021924 425332 0 388386 139123 632849 719286 225600 222591 15560 27941 1623592 1115278 530363 508314 160363 31556 1953121 1648811 566717 742852 47632 25995 3628759 2990802 4243108 3759649 X -2289987 -2110838 -2289987 -2110838 1953121 1648811 179149 0 X X 0 1 X 1 0 X 6833284 6977456 7737614 7691618 8171918 37411890 6833284 6977456 7737614 7691618 8171918 37411890 0 0 0 37411890 63301 58747 225410 499283 454487 1301228 6896585 7036203 7963024 8190901 8626405 38713118 0.96640 0.97580 0.00000 X 86981 59749 27232 360158 247400 112758 1176453 808129 368324 508314 DUE TO RANDOLPH HOSPITAL INC 2990802 2990802 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 SEPTEMBER 30, 2013. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 0 1 0 0 0 0 0 0 0 STEVE ELBIN 0 280014 0 0 0 360 0 0 0 4505 0 284879 0 0 PATRICIA VINOCUR 210730 0 0 0 531 0 0 0 5610 0 216871 0 0 0 ROBERT S CLAUSER 64087 100488 18628 0 90 120 0 0 2883 3346 85688 103954 0 0 KEUNG W LEE 308434 0 28765 0 383 0 0 0 11574 0 349156 0 0 0 JOHN F GAGE 271281 0 30836 0 1151 0 0 0 3716 0 306984 0 0 0 DOUGLAS E SCHULTZ 244720 0 27606 0 679 0 0 0 6961 0 279966 0 0 0 KATHLEEN RILEY 157877 0 22534 0 637 0 0 0 9126 0 190174 0 0 0 PART I, LINE 4B CERTAIN INDIVIDUALS ARE ALLOWED TO 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. SUPPLEMENTAL INFORMATION PART III PART I, LINE 1: SEVERAL OFFICERS OF RANDOLPH MEDICAL ASSOCIATES ARE COMPENSATED BY A RELATED TAX-EXEMPT ENTITY, RANDOLPH HOSPITAL, INC. THE HOSPITAL HAS A WRITTEN REIMBURSEMENT POLICY AND REQUIRES SUBSTANTIATION BEFORE ISSUING ANY REIMBURSEMENTS. ADDITIONALLY, OFFICER COMPENSATION AMOUNTS ARE DETERMINED USING A VARIETY OF SOURCES INCLUDING FORM 990 OF SIMILAR ORGANIZATIONS, COMPENSATION SURVEYS AND STATISTICS, AN INDEPENDENT CONSULTANT, AND A COMPENSATION COMMITTEE. ONCE A COMPENSATION PACKAGE IS APPROVED BY THE BOARD OF DIRECTORS, A WRITTEN EMPLOYMENT CONTRACT IS DRAFTED AND SIGNED BY THE APPLICABLE PARTIES. SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: THE ORGANIZATION RELIES ON THE GOVERNING BODY OF RANDOLPH HOSPITAL, INC. TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S EXECUTIVE DIRECTOR. THE HOSPITAL USES THE FOLLOWING METHODS: COMPENSATION COMMITTEE; INDEPENDENT COMPENSATION CONSULTANT; REVIEW OF FORM 990 OF OTHER SIMILAR ORGANIZATIONS; WRITTEN EMPLOYMENT CONTRACTS; COMPENSATION SURVEYS OR STUDIES; AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART II: WE ARE REQUIRED TO REPORT COMPENSATION OF KEY INDIVIDUALS THAT WORK FOR AND ARE PAID BY A RELATED ORGANIZATION. COMPENSAITON REPORTED ON THIS SCHEDULE DOES NOT NECESSARILY MEANT THAT THE COMPENSATION WAS PAID BY THIS ORGANIZATION. 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 FULL 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. MONTHLY CORPORATE COMPLIANCE MEETING TO UPDATE KEY INDIVIDUALS ON NEW ISSUES. BOARD OF DIRECTORS ARE REQUIRED TO ANNUALLY READ, SIGN AND REMIT COPY OF THE POLICY TO THE BOARD CHAIR. ALL BOARD MEMBERS ARE AWARE OF POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS ACQUIRES OUTSIDE COMPARATIVE SALARY DATA USED TO DETERMINE THE EXECUTIVE DIRECTOR'S SALARY. THERE ARE NO OTHER OFFICERS OF THE ORGANIZATION TO WHICH THIS POLICY WOULD APPLY. 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. PART VII ROBERT CLAUSER IS THE PRESIDENT OF RANDOLPH MEDICAL ASSOCIATES AND RANDOLPH SPECIALTY GROUP PRACTICE AND SPLITS HIS TIME BETWEEN THESE TWO ENTITIES. HIS TITLE WITH THE HOSPITAL IS VP OF PHYSICIAN PARTNERSHIPS AND EMPLOYER HEALTH. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE 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 RANDOLPH CANCER CENTER LLC 364 WHITE OAK STREET ASHEBORO NC 27204 562181482 HEALTHCARE NC 501(C)(3) LINE 11A, I RANDOLPH HOSPITAL INC 0 CENTRAL PIEDMONT SURGERY CENTER LLC 11221 ROE AVE SUITE 320 LEAWOOD KS 66211 264317497 HEALTHCARE KS N/A RELATED 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 RANDOLPH HOSPITAL K 81240 COST RANDOLPH HOSPITAL S 459159 COST RANDOLPH SPECIALTY GROUP R 582953 COST