2013-11-15T13:11:36-06:00 2012-12-31 560747981 DIXON HUGHES GOODMAN LLP PO BOX 1747 CHARLESTON WV 25326 990 2012-01-01 264058719 CAMDEN-CLARK PHYSICIAN CORPORATION CAMD 3044242202 800 GARFIELD AVENUE PARKERSBURG WV 26102 ALLEN R BUTCHER 3044242202 2013-11-14 1 SUSAN S DULL P00233523 3043430168 2012 2016-03-07 17:11:31Z ALLEN R BUTCHER 800 GARFIELD AVENUE PARKERSBURG WV 26102 16290473 0 X WWW.CCMH.ORG X 2008 WV TO SUPPORT, MANAGE, AND FURNISH FACILITIES, PERSONNEL, AND MEDICAL SERVICES TO INDIVIDUALS IN NEED. 5 3 129 5 0 0 0 0 8452616 16024609 0 0 42059 265864 8494675 16290473 0 0 0 0 6593119 12390589 0 0 0 4655012 9583019 11248131 21973608 -2753456 -5683135 3630642 2684615 1193242 1616535 2437400 1068080 X THE GENERAL PURPOSES OF THE CORPORATION ARE AS FOLLOWS: TO ESTABLISH, SUPPORT, MANAGE, AND FURNISH FACILITIES, PERSONNEL, AND SERVICES TO PROVIDE DIAGNOSTIC, THERAPEUTIC, WELLNESS, HEALTH PROMOTION, SURGICAL, AND OTHER PROFESSIONAL MEDICAL SERVICES TO SICK, INJURED, OR DISABLED PERSONS WITHOUT REGARD TO RACE, CREED, COLOR, SEX, NATIONAL ORIGIN, OR FINANCIAL STATUS, AND TO OTHERWISE PROMOTE THE QUALITY, ACCESSIBILITY, AND AFFORDABILITY OF SUCH PROFESSIONAL MEDICAL SERVICES. 1 0 10315556 7985279 CAMDEN CLARK PHYSICIAN CORPORATION EMPLOYS TWO MEDICAL ONCOLOGISTS AND TWO RADIATION ONCOLOGISTS, AND IN CONJUNCTION WITH CAMDEN CLARK MEMORIAL HOSPITAL CORPORATION, THESE PHYSICIANS PROVIDE A WIDE VARIETY OF CANCER TREATMENT OPTIONS AS WELL AS EDUCATION TO RESIDENTS OF THE MID-OHIO VALLEY SERVICE AREA. THROUGH THE HOSPITAL'S COLLABORATION WITH THE AMERICAN CANCER SOCIETY, THE DEVELOPMENT OF THE ORGANIZATION'S CANCER RESOURCE CENTER, A HAIR RESTORATION SALON, A PATIENT NAVIGATOR AND AN ONCOLOGY SOCIAL WORKER, THESE PHYSICIANS ARE ABLE TO HELP PROVIDE A HOLISTIC HEALING ENVIRONMENT THAT INCLUDES SUPPORT GROUPS FOR PATIENTS AND THEIR FAMILIES. 5096630 4466507 CAMDEN CLARK PHYSICIAN CORPORATION OFFERS SURGICAL SERVICES IN CONJUNCTION WITH CAMDEN CLARK MEMORIAL HOSPITAL CORPORATION. THE ORGANIAZATION EMPLOYS 6 SURGEONS WHO PROVIDE SURGICAL SERVICES IN A VARIETY OF DISCIPLINES, INCLUDING OPEN HEART, CARDIO-THORACIC, VASCULAR AND GENERAL SURGERY. 2813755 1853794 CAMDEN CLARK PHYSICIAN CORPORATION OFFERS OB/GYN SERVICES THROUGH A TEAM OF EMPLOYED PHYSICIANS AND IN COLLABORATION WITH CAMDEN CLARK MEMORIAL HOSPITAL CORPORATION. 3415286 1984893 CAMDEN CLARK PHYSICIAN CORPORATION STRIVES TO OFFER A COMPREHENSIVE RANGE OF INPATIENT, OUTPATIENT AND OUTREACH CLINIC SERVICES, INCLUDING PREVENTION, GUIDANCE, DIAGNOSIS, TREATMENT, RESTORATION, REHABILITATION AND OTHER EFFORTS AS MAY BE REQUIRED TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY IN WHICH IT SERVES. IN ADDITION TO THE CANCER, SURGICAL AND OB/GYN PROGRAMS DESCRIBED ABOVE, THE ORGANIZATION EMPLOYS PHYSICIANS WHO SPECIALIZE IN DIABETES AND NUTRITIONAL MANAGEMENT, BEHAVIORAL HEALTH AND HAS BEGUN TO BUILD A NETWORK OF EMPLOYED PRIMARY CARE PHYSICIANS THROUGHOUT THE COMMUNITY IN AN EFFORT TO ADDRESS WHAT IS BELIEVED TO BE A SIGNIFICANT SHORTAGE OF AVAILABLE PRIMARY CARE FOR THE RESIDENTS OF THE MID-OHIO VALLEY.ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF THE ORGANIZATION, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. OUR MISSION, IN CONJUNCTION WITH CAMDEN CLARK MEMORIAL HOSPITAL, IS TO SERVE THE COMMUNITY BY PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION. IN KEEPING WITH THIS COMMITMENT TO SERVICE ALL MEMBERS OF THE COMMUNITY, THE ORGANIZATION WILL PROVIDE THE FOLLOWING WHERE THE INDIVIDUAL'S NEED AND/OR AN INABILITY TO PAY COEXIST:* FREE CARE AND/OR SUBSIDIZED CARE* CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT OR BELOW COST* HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITYSERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE ORGANIZATION RECOGNIZES THESE AMOUNTS AS CHARITY CARE. 3415286 1984893 21641227 1 0 0 0 0 0 0 0 0 0 1 0 0 1 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 1 0 0 0 1 79 0 129 1 0 0 0 0 0 0 0 0 0 0 X 5 3 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 WV X X BRIAN STANDLEY 3044242202 800 GARFIELD AVENUE PARKERSBURG WV 26102 X KATHY G EDDY 1.00 X X 0 0 0 TERRY CAPEL MD 1.00 X X 0 0 0 DR DANIEL MCGRAW 40.00 X 846490 0 26024 JOE CAMPBELL 1.00 X 0 0 0 MICHAEL KING 5.00 X 0 539228 101033 ALLEN BUTCHER 5.00 X 0 336732 16825 JASON LANDERS 40.00 X 41443 0 5032 DR LISA CASALENUOVO 40.00 X 447112 0 24025 DR MICHAEL GALLOWAY 40.00 X 546242 0 20286 DR GABOR ALTDORFER 40.00 X 743952 0 19531 DR JOSE CRUZZAVALA 40.00 X 785439 0 9961 DR NIK SHAH 40.00 X 1000326 0 11451 DR SIVAMURTHY KYATHARI 40.00 X 532049 0 20761 4943053 875960 254929 17 0 1 0 ALLSCRIPTS LLC 24630 NETWORK PLACE CHICAGO IL 606731246 SOFTWARE SERVICES 167540 LOCUMTENENSCOM LLC PO BOX 405547 ATLANTA GA 303845547 PHYSICIAN FEES 122127 2 NET PATIENT REVENUE 621110 16024609 16024609 16024609 OTHER REVENUE 621110 265864 265864 265864 16290473 16290473 0 0 5080125 5056887 23238 5812310 5632129 180181 292821 283743 9078 744311 721237 23074 461022 446730 14292 1100 1100 813089 787883 25206 187 187 300844 291518 9326 1703 1650 53 446576 432732 13844 7460 7229 231 190360 184459 5901 587205 569002 18203 MEDICAL SUPPLIES 6058010 6058010 PROVISION FOR BAD DEBTS 897281 897281 REPAIRS AND MAINTENANCE 193397 187402 5995 PROFESSIONAL DEVELOPMEN 66257 64204 2053 19550 18944 606 21973608 21641227 332381 0 1 364469 188413 1811771 1535682 344450 13317 273950 0 1257762 596073 476365 661689 359637 285513 3630642 2684615 1193242 1616535 1193242 1616535 X 2437400 1068080 2437400 1068080 3630642 2684615 X -5683135 4313815 X 0 1 X 1 0 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: SCHEDULE A, PART I, LINE 3: ALTHOUGH THE ORGANIZATION QUALIFIES AS A HOSPITAL UNDER IRC SECTION 170(B)(1)(A)(III) AS SHOWN ON SCHEDULE A, PART I, LINE III, THE ORGANIZATION IS NOT A LICENSED HOSPITAL IN THE STATE OF WEST VIRGINIA, AND THEREFORE IT IS NOT REQUIRED TO COMPLETE FORM 990 SCHEDULE H. 1257762 596073 661689 661689 INSURANCE 280953 WORKERS COMPENSATION FUND 854 PREPAID EXPENSES 3706 285513 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: WEST VIRGINIA UNITED HEALTH SYSTEM ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES USING A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD IS MET. MANAGEMENT DETERMINED THERE WERE NO TAX UNCERTAINTIES THAT MET THE RECOGNITION THRESHOLD IN 2012 AND 2011. X 0 0 X 0 0 0 1 0 0 0 0 0 DR DANIEL MCGRAW 824490 0 0 0 22000 0 17050 0 8974 0 872514 0 0 0 MICHAEL KING 0 499728 0 0 0 39500 0 96711 0 4322 0 640261 0 0 ALLEN BUTCHER 0 302732 0 0 0 34000 0 13243 0 3582 0 353557 0 0 DR LISA CASALENUOVO 430112 0 0 0 17000 0 12813 0 11212 0 471137 0 0 0 DR MICHAEL GALLOWAY 523742 0 0 0 22500 0 15148 0 5138 0 566528 0 0 0 DR GABOR ALTDORFER 721452 0 0 0 22500 0 12699 0 6832 0 763483 0 0 0 DR JOSE CRUZZAVALA 762939 0 0 0 22500 0 6296 0 3665 0 795400 0 0 0 DR NIK SHAH 977826 0 0 0 22500 0 6250 0 5201 0 1011777 0 0 0 DR SIVAMURTHY KYATHARI 515049 0 0 0 17000 0 13406 0 7355 0 552810 0 0 0 PART I, LINE 1A MEMBERSHIPS AT THE FAMILY FITNESS CENTER ARE OFFERED TO EACH MEMBER OF THE SENIOR LEADERSHIP TEAM. THESE DUES ARE COVERED IN THE APPLICABLE EMPLOYMENT CONTRACTS. PART I, LINE 5 EACH PHYSICIAN HAS A PRODUCTIVITY BONUS IN THEIR CONTRACT. THIS BONUS IS BASED ON PRODUCING OVER A SET RELATIVE VALUE UNIT (RVU) DURING THE YEAR. THERE IS ALSO A COMPONENT FOR EACH PHYSICIAN BASED ON COLLECTIONS. AS AN EXAMPLE, IF THE PHYSICIAN PRODUCES IN EXCESS OF THEIR ESTABLISHED RVU NUMBER AT THE 90TH PRECENTILE, BUT COLLECTS AT THE 75TH PERCENTILE, THE BONUS IS THEN BASED ON THE 75TH PERCENTILE. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 DURING 2012, THE ORGANIZATION BEGAN TO BUILD A PRIMARY CARE PRESENCE AS IT IS BELIEVED THAT THERE IS A LACK OF ADEQUATE PRIMARY CARE SERVICES IN THIS COMMUNITY. THIS WAS DONE THROUGH THE ACQUISITION OF TWO EXISTING PRACTICES AS WELL AS THROUGH THE HIRING OF ADDITIONAL PRIMARY CARE PHYSICIANS. FORM 990, PART VI, SECTION A, LINE 6 CAMDEN-CLARK HEALTH SERVICES, INC. (AS OF MARCH 1, 2011, AFFILIATED WITH WEST VIRGINIA UNITED HEALTH SYSTEM), A NON-PROFIT, TAX-EXEMPT CORPORATION IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A CAMDEN-CLARK HEALTH SERVICES, INC., THE ORGANIZATION'S SOLE MEMBER, ELECTS NO LESS THAN FIVE BUT NO MORE THAN NINE INDIVIDUALS OF THE BOARD AT THE ANNUAL MEETING. THE TERM FOR EACH DIRECTOR IS THREE YEARS. FORM 990, PART VI, SECTION A, LINE 7B CAMDEN-CLARK HEALTH SERVICES, INC., THE ORGANIZATION'S SOLE MEMBER, SHALL APPROVE ALL MATTERS REGARDING CAMDEN-CLARK PHYSICIAN CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER AND DIRECTOR OF FINANCE REVIEW THE COMPLETED FORM PRIOR TO FILING. AFTER THE RETURN IS FILED, A COPY IS SENT TO THE BOARD OF DIRECTORS FOR THEIR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C TO IDENTIFY AND MONITOR ANY CONFLICTS, A SIGNED CONFLICT OF INTEREST STATEMENT IS REQUIRED FROM BOARD MEMBERS OF THE ORGANIZATION AND KEY INDIVIDUALS THAT ARE IN A POSITION TO MAKE OR INFLUENCE DECISIONS. IF AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST IS OBSERVED OR DISCLOSED, THE ORGANIZATION INVOKES THE PROCEDURES SET OUT IN THE POLICY/BYLAWS FOR ADDRESSING THE CONFLICT OF INTEREST. FOR KEY INDIVIDUALS (EMPLOYEES), A SPECIFIC CONFLICT OF INTEREST STANDARD IN THE ORGANIZATION'S CODE OF ETHICS AND BUSINESS CONDUCT ALSO EXISTS. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE DIRECTOR'S PAY IS REVIEWED AND APPROVED BY THE CAMDEN-CLARK MEMORIAL HOSPITAL (CCMH) BOARD OF DIRECTORS. A COMPENSATION COMMITTEE CONSISTING OF ALL NON-PHYSICIAN MEMBERS OF THE CCMH BOARD REVIEWS AND APPROVES PAY FOR THE PHYSICIANS. THEIR CONTRACTS ARE BASED ON MEDICAL GROUP MANAGEMENT ASSOCIATION STANDARDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ALSO AVAILABLE ON THE WV HEALTHCARE AUTHORITY'S WEBSITE. FORM 990, PART VII, SECTION A DR. DANIEL MCGRAW IS COMPENSATED FOR HIS POSITION AS A PHYSICIAN WITH THE ORGANIZATION, NOT FOR SERVING ON THE BOARD OF DIRECTORS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFERS FROM CAMDEN-CLARK MEMORIAL HOSPITAL 4,313,815. CAMDEN-CLARK HEALTH SERVICES INC 800 GARFIELD AVENUE PARKERSBURG WV 26102 550769602 AIDS, STRENGTHENS, AND SUPPORTS CAMDEN-CLARK MEMORIAL HOSPITAL. WV 501(C)(3) LINE 11A, I N/A 0 CAMDEN-CLARK MEMORIAL HOSPITAL CORPORATION 800 GARFIELD AVENUE PARKERSBURG WV 26102 311524546 OPERATES AN ACUTE CARE AND EMERGENCY HOSPITAL FACILITY. WV 501(C)(3) LINE 3 N/A 0 AUXILIARY OF CAMDEN-CLARK MEMORIAL HOSPITAL OF PARKERSBURG 800 GARFIELD AVENUE PARKERSBURG WV 26102 550386283 PROMOTES ADVANCEMENT AND WELFARE OF CAMDEN-CLARK MEMORIAL HOSPITAL. WV 501(C)(3) LINE 11A, I N/A 0 CAMDEN-CLARK FOUNDATION INC 800 GARFIELD AVENUE PARKERSBURG WV 26102 550667789 RAISE AND MANAGE FUNDS FOR CAMDEN-CLARK MEMORIAL HOSPITAL. WV 501(C)(3) LINE 11A, I N/A 0 WV UNITED HEALTH SYSTEM 1000 TECHNOLOGY DRIVE FAIRMONT WV 26554 550175471 HEALTHCARE ACCESS WV 501(C)(3) LINE 11A, I N/A 0 WEST VIRGINIA UNIVERSITY HOSPITALS INC PO BOX 8034 MORGANTOWN WV 26506 550643304 PATIENT CARE WV 501(C)(3) LINE 3 N/A 0 WEST VIRGINIA UNIVERSITY HOSPITALS EAST 2000 FOUNDATION WAY MARTINSBURG WV 25401 202337985 HEALTHCARE ACCESS WV 501(C)(3) LINE 11A, I N/A 0 CITY HOSPITAL INC 2000 FOUNDATION WAY MARTINSBURG WV 25401 550383321 PATIENT CARE WV 501(C)(3) LINE 3 N/A 0 JEFFERSON MEMORIAL HOSPITAL 2000 FOUNDATION WAY MARTINSBURG WV 25401 550359755 PATIENT CARE WV 501(C)(3) LINE 3 N/A 0 CITY HOSPITAL FOUNDATION 2000 FOUNDATION WAY MARTINSBURG WV 25401 311118075 HOSPITAL SUPPORT WV 501(C)(3) LINE 11A, I N/A 0 JEFFERSON HEALTHCARE FOUNDATION 2000 FOUNDATION WAY MARTINSBURG WV 25401 550768901 HOSPITAL SUPPORT WV 501(C)(3) LINE 11A, I N/A 0 UNITED HOSPITAL CENTER INC 327 MEDICAL PARK DRIVE BRIDGEPORT WV 26330 550525724 PATIENT CARE WV 501(C)(3) LINE 3 N/A 0 UNITED PHYSICIANS CARE INC 686 SOUTH PIKE STREET SHINNSTON WV 26431 550638563 PATIENT CARE WV 501(C)(3) LINE 3 N/A 0 UNITED HOSPITAL FOUNDATION 327 MEDICAL PARK DRIVE BRIDGEPORT WV 26330 550621706 HOSPITAL SUPPORT WV 501(C)(3) LINE 11A, I N/A 0 WVU HEALTHCARE CO-OP PO BOX 8059 MORGANTOWN WV 26506 550650441 SUPPORT WV 501(C)(3) LINE 11A, I N/A 0 UNITED SUMMIT CENTER 6 HOSPITAL PLAZA CLARKSBURG WV 26301 550752788 BEHAVIORAL HEALTH WV 501(C)(3) LINE 3 N/A 0 ALLIED HEALTH SERVICES INC PO BOX 782 MORGANTOWN WV 26507 550652017 MEDICAL LAB WV WV UNITED HEALTH SYSTEM C 0 WEST VIRGINIA UNITED INSURANCE SERVICES 1000 TECHNOLOGY DRIVE SUITE 2320 FAIRMONT WV 26554 550756055 PROVIDER NETWORK WV WV UNITED HEALTH SYSTEM C 0 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1