2013-07-08T11:08:27-05:00 2012-12-31 273605969 CBIZ KIRKLAND RUSS MURPHY & TAPP 13577 FEATHER SOUND DRIVE 400 CLEARWATER FL 33762 990 2012-01-01 042121377 THE SHRINERS' HOSPITAL FOR CHILDREN SHRI 8132810300 POST OFFICE BOX 31356 TAMPA FL 336313356 DOUGLAS MAXWELL 8132810300 2013-07-08 1 NATHAN SMITH P00543757 7275721400 2012 2016-02-24 21:20:13Z DOUGLAS MAXWELL 2900 ROCKY POINT DRIVE TAMPA FL 33607 400340925 0 X HTTP://WWW.SHRINERSHQ.ORG/ X 1925 MA WE PROVIDE PEDIATRIC SPECIALTY CARE WITHOUT FINANCIAL OBLIGATION TO PATIENTS OR THEIR FAMILIES. 20 17 531 1000 0 0 42742971 41166474 3056204 5925184 74899338 45834475 223337 1598055 120921850 94524188 0 0 0 0 35707985 34553667 0 0 0 26050145 28079499 61758130 62633166 59163720 31891022 865660518 941556297 32939050 13675966 832721468 927880331 X SEE SCHEDULE OSHRINERS HOSPITALS FOR CHILDREN IN BOSTON AND SPRINGFIELD OFFER "CHARITY CARE" AS PART OF AN INTERNATIONAL NETWORK OF PEDIATRIC HOSPITALS DEDICATED TO PROVIDING EXCELLENT PATIENT CARE, RESEARCH, AND EDUCATION FOR ORTHOPAEDIC CONDITIONS AND BURNS.SHRINERS HOSPITALS FOR CHILDREN-BOSTON SPECIALIZES IN PROVIDING COMPREHENSIVE ACUTE CARE AND RECONSTRUCTIVE AND REHABILITATIVE CARE TO CHILDREN WHO HAVE BEEN BURNED, INCLUDING ACUTE BURNS, SMOKE INHALATION INJURY, RECONSTRUCTIVE SURGERY FOR HEALED BURNS, AND OTHRE RELATED CONDITIONS.SHRINERS HOSPITALS FOR CHILDREN-SPRINGFIELD SPECIALIZES IN CARING FOR CHILDREN WITH ORTHOPAEDIC CONDITIONS AND INJURIES SUCH AS SCOLIOSIS, CLUBFOOT, AND ORTHOPAEDIC CONDITIONS RELATED TO CEREBRAL PALSY AND SPINAL BIFIDA. FOR MORE INFORMATION, VISIT HTTP://WWW.SHRINERSHQ.ORG/ OR CALL 1-800-241-GIFT. 0 0 38443588 3890062 TREATMENT OF PEDIATRIC BURN VICTIMS: ADMISSIONS: 515OUTPATIENT CLINIC VISITS: 5,314OUTPATIENT CLINIC SURGERIES: 524 20112122 2035122 TREATMENT OF ORTHOPEDIC PEDIATRIC PATIENTS: ADMISSIONS: 160OUTPATIENT CLINIC VISITS: 13,603OUTPATIENT CLINIC SURGERIES: 300 4077456 MEDICAL RESEARCH IS PERFORMED AND HAS A STRONG, POSITIVE IMPACT ON THE CARE AND CURE OF CHILDREN WITH ORTHOPAEDIC PROBLEMS, BURN AND SPINAL CORD INJURIES. SHRINERS HOSPITALS FOR CHILDREN IS COMMITTED TO THE SUSTAINED INVESTMENT IN CLINICALLY USEFUL RESEARCH SO THAT FUNDAMENTAL KNOWLEDGE CAN BE ACQUIRED, IMPROVING THE QUALITY OF LIFE FOR CHILDREN WITH ORTHOPAEDIC PROBLEMS, BURN AND SPINAL CORD INJURIES. 62633166 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 82 0 1 531 1 0 0 0 0 0 1 1 0 0 0 1 1 0 X 20 17 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X X SHARON RUSSELL 8132810300 2900 ROCKY POINT DR TAMPA FL 336071435 CHARLES CLAYPOOL 5.00 X 0 0 0 GARY DUNWOODY 5.00 X 0 0 0 RAOUL L FREVAL 5.00 X 0 0 0 DOUGLAS MAXWELL 20.00 X X 0 18000 0 GEORGE MITCHELL 5.00 X 0 0 0 GENE BRACEWELL 5.00 X X 0 0 0 RODNEY PINKHAM 5.00 X 0 0 0 DAVID S MCKECHNIE 5.00 X 0 0 0 HAROLD F JENNINGS CPA 5.00 X 0 0 0 MICHAEL G SEVERE 5.00 X X 0 47500 0 DAVID H BURSTEIN 5.00 X 0 0 0 KEVIN J HECHT ESQ 5.00 X 0 0 0 RICHARD E JOHNSON 5.00 X X 0 0 0 BOBBY B SIMMONS 5.00 X 0 0 0 G STEPHEN GETMAN ESQ 5.00 X 0 0 0 ALAN W MADSEN 5.00 X X 0 49300 0 SKIP DF STANAWAY 5.00 X 0 0 0 PETER P DIAZ MD 5.00 X 0 0 0 JOHN A CINOTTO 5.00 X 0 0 0 STEVEN E BEHE 5.00 X 0 0 0 JACK H JONES 35.00 X 0 158870 0 CHARLES H WEAVER 5.00 X 0 0 0 DAVID M DRVARIC MD 40.00 X 413257 0 20024 PETER D MASSO MD 40.00 X 301644 0 23162 CLIFFORD D'ESMOND 40.00 X 220890 0 2676 ALAN J FISCHMAN 40.00 X 188977 0 6859 PATRICIA KING 40.00 X 178027 0 1628 1302795 273670 54349 47 0 1 0 MASSACHUSETTS GENERAL HOSPITAL PO BOX 350096 BOSTON MA 02241 OUTSIDE PATIENT CARE 8910837 HEALTH NEW ENGLAND 1 MONARCH PLACE 1500 SPRINGFIELD MA 01144 EMPLOYEE BENEFITS 1711019 OWENS & MINOR 9120 LOCKWOOD BLVD MECHANICSVILLE VA 23116 MEDICAL SUPPLIES 887394 SPRINGFIELD ANESTHESIA SERVICE 908 ALLEN ST SPRINGFIELD MA 01101 ANESTHESIOLOGY SERVICES 503220 CARDINAL HEALTH PHARMACEUTICAL 7000 CARDINAL PLACE DUBLIN OH 43017 PHARMACEUTICAL SUPPLIES 395246 35 38442340 2724134 41166474 PATIENT SERVICE 621110 5925184 5925184 5925184 27565575 27565575 1350225 0 1350225 1350225 1350225 324066530 305721653 75977 18344877 -75977 18268900 18268900 118123 19107 99016 99016 MISCELLANEOUS 900099 148814 148814 148814 94524188 5925184 0 47432530 X 24778592 24778592 4319406 4319406 3485139 3485139 1970530 1970530 1665907 1665907 10557055 10557055 182629 182629 156996 156996 3320810 3320810 334533 334533 4473798 4473798 423934 423934 MEDICAL SUPPLIES 5657349 5657349 PATIENT TRAVEL COSTS 910417 910417 DUES AND REGISTRATIONS 145436 145436 POSTAGE 70311 70311 180324 180324 62633166 62633166 0 0 382551 701420 426431 884084 938039 635784 483136 146969454 69316207 79969109 77653247 783580205 861238972 208785 115052 865660518 941556297 2579658 2266797 527170 906169 29832222 10503000 32939050 13675966 X 832721468 927880331 832721468 927880331 865660518 941556297 31891022 63267841 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 774831322 106867079 23391509 858306892 760025402 29611840 14805920 774831322 698824389 83046382 21845369 760025402 604354755 117592699 23123065 698824389 834575000 -216021898 14198347 604354755 1.00000 0.00000 0.00000 0 1 1 303990 303990 107661606 39755943 67905663 416959 382357 34602 38466737 29177907 9288830 120162 120162 77653247 RELATED PARTY PAYABLES 10503000 10503000 117702889 63267841 -1665907 61601934 56100955 38423233 38423233 94524188 60986366 19107 19107 60967259 1665907 1665907 62633166 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS (INCLUDING UNRESTRICTED FUND BALANCES) ARE THE PRIMARY SOURCE OF SUPPORT FROM WHICH SHRINERS HOSPITALS FOR CHILDREN PERFORMS ITS PROGRAM SERVICES TO ACHIEVE ITS PRIMARY EXEMPT PURPOSE. PART XI, LINE 2D - OTHER ADJUSTMENTS: INVESTMENT MANAGEMENT FEES RECLASSIFIED TO EXPENSES -1,665,907. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSES RECLASSIFIED FROM EXPENSES -19,107. FUNDING REVENUES RECLASSIFIED FROM OTHER CHANGES IN FUND BALANCE 38,442,340. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSES RECLASSIFIED TO NET WITH REVENUES 19,107. PART XII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT MANAGEMENT FEES RECLASSIFIED FROM REVENUES 1,665,907. GOLF TOURNAMENT 8106 8106 1311 FOOTBALL GAMES 89813 89813 14528 5 20204 20204 3268 118123 118123 19107 19107 99016 1 1 X 1 X 300.000000000000 1 X 1 1 0 1 1 58555710 5925184 52630526 0.84030 58555710 5925184 52630526 0.84030 4077456 4077456 0.06510 4077456 4077456 0.06510 62633166 5925184 56707982 0.90540 0 0 2 1 SHRINERS HOSPITAL FOR CHILDREN-BOSTON

51 BLOSSOM STREET BOSTON MA 021142699

X X X X A 2 SHRINERS HOSPITAL FOR CHILDREN-SPRINGFIE

516 CAREW STREET SPRINGFIELD MA 01104

X X X X A SHRINERS HOSPITAL FOR CHILDREN-GROUP A 1 1 300.000000000000 1 400.000000000000 1 X X 1 0 0 0 0 X X 0 0 PART I, LINE 3C: SHRINERS HOSPITALS FOR CHILDREN OFFERS SPECIALIZED MEDICAL SERVICES PERTAINING TO ORTHOPAEDIC CONDITIONS, BURNS, SPINAL CORD INJURIES AND CLEFT LIP AND PALATE. UPON PATIENT ADMITTANCE FOR ONE OF THESE CONDITIONS, SHRINERS HOSPITALS FOR CHILDREN REVIEWS THE PATIENT'S "ABILITY TO PAY" USING FEDERAL POVERTY GUIDELINES SPECIFIED IN SCHEDULE H, PART I, LINES 3A AND 3B, AND PROVIDES FREE OR DISCOUNTED CARE PURSUANT TO THESE GUIDELINES. NEVERTHELESS, SHRINERS HOSPITALS FOR CHILDREN WILL ALWAYS SERVE THESE SPECIALIZED NEEDS FOR ALL OF ITS PATIENTS, REGARDLESS OF THEIR "ABILITY TO PAY". AS SUCH, SHRINERS HOSPITALS FOR CHILDREN DID NOT APPLY ANY INCOME-BASED CRITERIA, ASSET TEST, OR OTHER MEANS TEST OR THRESHOLD FOR PROVIDING FREE CARE TO PATIENTS IN 2012. PART I, LINE 7: A GENERAL LEDGER ACCOUNTING SYSTEM WAS USED TO CALCULATE THE AMOUNTS REPORTED IN PART I, LINE 7. THE SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT AND OUTPATIENT). A COST-TO-CHARGE RATIO IS NOT PART OF THE SYSTEM AND IS NOT APPLICABLE TO SHRINERS HOSPITALS FOR CHILDREN. PART III, LINE 4: BAD DEBT EXPENSE IS NOT APPLICABLE TO SHRINERS HOSPITALS FOR CHILDREN, AND AS SUCH, IS NOT PART OF THE FOOTNOTES IN ITS FINANCIAL STATEMENTS. SHRINERS HOSPITALS FOR CHILDREN PROVIDES PATIENT CARE REGARDLESS OF THEIR ABILITY TO PAY. AS SUCH, THERE ARE NO REVENUES AGAINST WHICH A BAD DEBT COULD ARISE. PART III, LINE 9B: SHRINERS HOSPITALS FOR CHILDREN PROVIDES PATIENT CARE REGARDLESS OF THEIR ABILITY TO PAY. AS SUCH, THERE IS NO DEBT COLLECTION POLICY. PART VI, LINE 2: SHRINERS HOSPITALS FOR CHILDREN PROVIDES PEDIATRIC, ORTHOPAEDIC, AND BURN CARE REGARDLESS OF THEIR ABILITY TO PAY. PART VI, LINE 3: SHRINERS HOSPITALS FOR CHILDREN POSTS ITS CHARITY CARE POLICY IN ADMISSION AREAS, EMERGENCY ROOMS, AND OTHER AREAS OF FACILITIES WHERE ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT, AND PROVIDES A COPY OF ITS POLICY TO PATIENTS AS PART OF THE INTAKE PROCESS AND WITH DISCHARGE MATERIALS. PART VI, LINE 4: SHRINERS HOSPITALS FOR CHILDREN (THROUGH THIS ENTITY AND ITS RELATED ENTITY) SERVE CHILDREN IN NEED OF SPECIALIZED ORTHOPAEDIC AND BURN CARE ACROSS THE ENTIRE UNITED STATES. PART V, LINE 8 FACILITY REPORTING GROUP A SEE BELOW FACILITY 1 -- SHRINERS HOSPITAL FOR CHILDREN-BOSTON PART V, SECTION B, LINE 12H: PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE BASED UPON THEIR INCOME LEVEL COMPARED TO THE FEDERAL POVERTY GUIDELINES AND INTERNAL POLICY. FACILITY 1 -- SHRINERS HOSPITAL FOR CHILDREN-BOSTON PART V, SECTION B, LINE 20D: THE AMOUNT CHARGED IS CONSISTENT FOR ALL PAYER CLASSES, PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE BASED ON THEIR INCOME LEVEL AND FEDERAL POVERTY GUIDELINES. FACILITY 2 -- SHRINERS HOSPITAL FOR CHILDREN-SPRINGFIE PART V, SECTION B, LINE 12H: PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE BASED UPON THEIR INCOME LEVEL COMPARED TO THE FEDERAL POVERTY GUIDELINES AND INTERNAL POLICY. FACILITY 2 -- SHRINERS HOSPITAL FOR CHILDREN-SPRINGFIE PART V, SECTION B, LINE 20D: THE AMOUNT CHARGED IS CONSISTENT FOR ALL PAYER CLASSES, PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE BASED ON THEIR INCOME AND FEDERAL POVERTY GUIDELINES. X X 1 1 X X 0 1 0 0 0 0 0 0 0 JACK H JONES 0 158870 0 0 0 0 0 0 0 0 0 158870 0 0 DAVID M DRVARIC MD 413257 0 0 0 0 0 17000 0 3024 0 433281 0 0 0 PETER D MASSO MD 301644 0 0 0 0 0 17000 0 6162 0 324806 0 0 0 CLIFFORD D'ESMOND 220890 0 0 0 0 0 0 0 2676 0 223566 0 0 0 ALAN J FISCHMAN 188977 0 0 0 0 0 0 0 6859 0 195836 0 0 0 PATRICIA KING 178027 0 0 0 0 0 0 0 1628 0 179655 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS ORGANIZED AS A NONPROFIT CORPORATION WITH MEMBERS. MEMBERS HAVE THE RIGHT TO ELECT PERSONS BELONGING TO THE GOVERNING BODY, AND TO APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BODY. COMPENSATION IS NOT PROVIDED FOR BEING A MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION HAS APPROXIMATELY 1,400 MEMBERS WHOM ARE APPOINTED FROM THE TOTAL MEMBERSHIP OF SHRINERS INTERNATIONAL (A RELATED ORGANIZATION). MEMBERS MAY ELECT PERSONS ON THE ORGANIZATION'S GOVERNING BODY, AND MAY APPROVE SIGNIFICANT DECISIONS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B UNDER THE BYLAWS OF THE ORGANIZATION, SIGNIFICANT DECISIONS OF THE GOVERNING BODY REQUIRE APPROVAL BY THE ORGANIZATION'S 1,400 MEMBERS (SUCH AS CHANGES TO THE BYLAWS, OR SIGNIFICANT RESTRUCTURING OR EXTRAORDINARY EVENTS). THE ORGANIZATION'S MEMBERS ALSO MAY ELECT PERSONS TO SERVE ON THE ORGANIZATION'S GOVERNING BODY. THE ORGANIZATION'S MEMBERS DO NOT HAVE CONTROL OVER THE GENERAL OPERATIONS OR FINANCIAL MATTERS OF THE ORGANIZATION. ELECTIONS ARE HELD ANNUALLY BY THE MEMBERS AT VARYING LOCATIONS IN THE U.S.. VOTING IS DECIDED WITH SIMPLE MAJORITY, WHERE EACH MEMBER'S VOTE IS EQUAL WEIGHTED. ELECTED PERSONS SERVE A THREE-YEAR TERM ON THE BOARD OF TRUSTEES, A ONE-YEAR TERM ON THE BOARD OF DIRECTORS, A ONE-YEAR TERM FOR THE ORGANIZATION'S PRESIDENT, AND A ONE-YEAR TERM FOR THE ORGANIZATION'S TREASURER. THE ORGANIZATION'S OFFICERS ARE NOT ELECTED, AND INSTEAD ARE HIRED BY COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11 A FULL VERSION OF FORM 990 AS FILED WITH THE IRS IS MADE AVAILABLE TO EACH VOTING MEMBER OF THE GOVERNING BODY AND/OR DESIGNATED COMMITTEE RESPONSIBLE FOR PERFORMING A REVIEW PROCESS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY AND ALL MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTING INTERESTS OR STATE "NONE" ON THE ANNUAL CONFLICT OF INTEREST FORM. POTENTIAL CONFLICTS ARE DETERMINED BY THE BOARD OF DIRECTORS. THE PERSON(S) HAVING A POTENTIAL CONFLICT OF INTEREST ARE PROHIBITED FROM PARTICIPATING IN DELIBERATIONS/DECISIONS IN THE TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15 A SALARY & PERSONNEL COMMITTEE IS INVOLVED WITH ALL COMPENSATION AND APPROVES WAGES FOR MANAGEMENT AND COMPARES THESE SALARIES TO VARIOUS MARKET INDICATORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS (INCLUDING ITS CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS) ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 10,557,055. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,557,055. AUDIT COMMITTEE OVERSIGHT PROCESS FORM 990, PART XII, LINE 2C EXPLANATION: THE ORGANIZATION HAS NOT CHANGED (DURING THE CURRENT YEAR) ITS OVERSIGHT PROCESS OR ITS SELECTION PROCESS REGARDING THE COMMITTEE RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. SHRINERS HOSPITALS FOR CHILDREN EMPLOYEE DISASTER RELIEF FUND 2900 ROCKY POINT DRIVE TAMPA FL 33607 263733381 DISASTER RELIEF DC 501(C)(3) 9 NO 0 SHRINERS HOSPITALS FOR CHILDREN POST OFFICE BOX 31356 TAMPA FL 336313356 362193608 HOSPITAL SYSTEM CO 501(C)(3) 3 NO 0 SHRINERS INTERNATIONAL POST OFFICE BOX 31356 TAMPA FL 336313356 362158164 FOUNDED SHRINERS HOSPITALS FOR CHILDREN IA 501(C)(10) N/A NO 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 SHRINERS HOSPITALS FOR CHILDREN C 38442340 SHRINERS HOSPITALS FOR CHILDREN O SHRINERS HOSPITALS FOR CHILDREN E 10503000