2013-08-12T13:40:25-05:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 561853201 RANDOLPH MEDICAL ASSOCIATES RAND 3366255151 218C FOUST ST ASHEBORO NC 27203 ROBERT S CLAUSER 3366255151 2013-08-07 1 AMY BIBBY P00445891 8282542254 2011 2016-02-24 21:20:13Z X ROBERT S CLAUSER 218C FOUST ST ASHEBORO NC 27203 8190901 0 X N/A X 1993 NC OPERATING SIX HEALTHCARE PRACTICES IN RANDOLPH COUNTY, NC 7 4 88 4 0 0 0 0 7737614 7691618 0 0 225410 499283 7963024 8190901 0 0 0 0 5448878 5926435 0 0 0 2091679 2062431 7540557 7988866 422467 202035 2297412 1953121 6065073 4243108 -3767661 -2289987 RANDOLPH MEDICAL ASSOCIATES WAS FORMED TO PROMOTE, IMPROVE AND ENHANCE THE QUALITY OF HEALTH CARE SERVICES IN RANDOLPH COUNTY, NC AND SURROUNDING COUNTIES BY PROVIDING PHYSICIANS AND OTHER MEDICAL SERVICES TO THE COMMUNITY. 0 0 7503628 7691618 RANDOLPH MEDICAL ASSOCIATES WAS ORGANIZED FOR THE PURPOSE OF PROMOTING COMMUNITY HEALTH THROUGH THE PROVISION OF HEALTH CARE SERVICES TO THE MEDICALLY UNDER-SERVED POPULATIONS OF RANDOLPH AND SURROUNDING COUNTIES. ITS ACTIVITIES INCLUDE PROMOTING AND CARRYING ON OF EDUCATIONAL ACTIVITIES RELATING TO THE CARE OF THE SICK, INJURED OR DISABLED. RANDOLPH MEDICAL ASSOCIATES PROVIDED CARE TO A TOTAL OF 69,531 PATIENTS DURING THE CALENDAR YEAR 2012 (68,346 OFFICE VISITS AND 1,185 HOSPITAL VISITS). 7503628 1 0 0 0 0 0 0 0 0 0 1 0 0 1 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 0 1 44 0 1 88 1 0 0 0 0 0 0 0 0 0 0 X 7 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X X LINDA CROWSHAW 3366255151 364 WHITE OAK STREET ASHEBORO NC 27204 X GLENN MAC PUGH 2.00 X X 0 0 0 SAM RANKIN JR 2.00 X X 0 0 0 STEVE EBLIN 2.00 X X 0 187570 35406 SAM CRANFORD JR 2.00 X 0 0 0 BETH RUSSELL 2.00 X 0 0 0 PATRICIA VINOCUR 40.00 X 238305 0 33206 ROBERT CLAUSER 20.00 X X 144566 0 12340 MURRAY S MARSH JR 2.00 X 0 0 0 LYNWOOD R WHITE 2.00 X 0 266539 28491 KEUNG LEE 40.00 X 327310 0 42774 JOHN GAGE 40.00 X 334097 0 25666 DOUGLAS SCHULTZ 40.00 X 315116 0 24681 MAURA HAMRICK 40.00 X 190098 0 25352 KATHLEEN RILEY 40.00 X 173359 0 9489 ROBERT E MORRISON 2.00 X 0 1112524 182900 1722851 1566633 420305 9 1 1 0 MISYS HEALTHCARE SYSTEMS LLC 8529 SIX FORKS ROAD RALEIGH NC 27615 COMPUTER MAINTENANCE, MISC. SERVICES 289124 QUEST DIAGNOSTICS INC PO BOX 740736 ATLANTA GA 30374 OUTSIDE LAB SERVICES 109616 2 PATIENT SERVICE REVENU 621300 7691618 7691618 7691618 OTHER REVENUE 900099 445276 445276 AFFILIATE MGMT 900099 54007 54007 499283 8190901 7691618 0 499283 353041 4527 348514 4558496 4558496 701269 654845 46424 313629 292867 20762 4432 4432 7241 7241 245909 245909 19732 19732 383183 320886 62297 22283 22283 391255 391255 28790 28790 5242 5242 140467 140467 38570 38570 MEDICAL SUPPLIES 620913 620913 BAD DEBTS 132729 132729 MISCELLANEOUS 21685 21685 7988866 7503628 485238 0 786080 388386 769165 632849 177599 225600 39597 15560 2129563 1599200 448588 530363 76383 160363 2297412 1953121 2032698 566717 47632 4032375 3628759 6065073 4243108 X -3767661 -2289987 -3767661 -2289987 2297412 1953121 X 202035 1275639 X X 0 1 1 X 0 X 6290477 6833284 6977456 7737614 7691618 35530449 6290477 6833284 6977456 7737614 7691618 35530449 0 0 0 35530449 35355 63301 58747 225410 499283 882096 6325832 6896585 7036203 7963024 8190901 36412545 0.97580 0.98740 0.00000 X 86981 65273 21708 403570 303071 100499 1639012 1230856 408156 530363 OTHER RECEIVABLES 160363 160363 DUE TO RANDOLPH HOSPITAL INC. 3628759 3628759 8190901 7988866 202035 1275639 1275639 1477674 9466540 1275639 1275639 8190901 0 8190901 7988866 0 7988866 0 7988866 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE. IT WAS DETERMINED THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER TO RELATED PARTY 1,275,639. PART XII, LINE 2D - OTHER ADJUSTMENTS: EQUITY TRANSFER TO RELATED PARTY 1,275,639. 0 1 0 0 0 0 0 0 0 STEVE EBLIN 0 187210 0 0 0 360 0 30804 0 4602 0 222976 0 0 PATRICIA VINOCUR 217721 0 20000 0 584 0 25934 0 7272 0 271511 0 0 0 ROBERT CLAUSER 144386 0 0 0 180 0 5733 0 6607 0 156906 0 0 0 LYNWOOD R WHITE 0 264955 0 0 0 1584 0 24296 0 4195 0 295030 0 0 KEUNG LEE 310234 0 16818 0 258 0 33000 0 9774 0 370084 0 0 0 JOHN GAGE 262481 0 70346 0 1270 0 22000 0 3666 0 359763 0 0 0 DOUGLAS SCHULTZ 230546 0 83912 0 658 0 17807 0 6874 0 339797 0 0 0 MAURA HAMRICK 122763 0 66892 0 443 0 16500 0 8852 0 215450 0 0 0 KATHLEEN RILEY 155748 0 16974 0 637 0 0 0 9489 0 182848 0 0 0 ROBERT E MORRISON 0 387202 0 0 0 725322 0 158990 0 23910 0 1295424 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. 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. THE SPLIT-DOLLAR LIFE INSURANCE AGREEMENT INVOLVES THE PAYMENT OF PREMIUMS BY THE HOSPITAL FOR A LIFE INSURANCE POLICY, THE BENEFITS OF WHICH ARE SPLIT BETWEEN THE EMPLOYEES' BENEFICIARIES AND THE HOSPITAL UP TO THE AMOUNT OF PREMIUMS PAID. PREMIUMS PAID UNDER THIS PLAN WILL CONTINUE UNTIL THE AGREEMENT IS TERMINATED OR UPON THE DEATH OF THE INSURED EMPLOYEES. PREMIUMS PAID UNDER THE SPLIT-DOLLAR INSURANCE POLICY WERE $9,822 FOR THE FISCAL YEAR. ROBERT E. MORRISON RECEIVED A PAYAOUT OF PREVIOUSLY DEFERRED COMPENSATION FROM THE NONQUALIFIED SUPPLEMENTAL DEFERRED COMPENSATION PLAN IN 2012 IN THE AMOUNT OF $723,738. TOTAL CONTRIBUTIONS TO THIS PLAN FOR THE FISCAL YEAR TOTALED $927,287. THE BENEFIT OBLIGATION IS RECORDED IN OTHER LONG-TERM LIABILITIES. FOR THE YEAR, THE FOLLOWING INDIVIDUALS ACCRUED COMPENSATION UNDER THE SERP: STEVE EBLIN $9,470 ROBERT MORRISON $129,012 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 1: SEVERAL OFFICERS OF RANDOLPH MEDICAL ASSOCIATES ARE COMPENSATED BY A RELATED TAX-EXEMPT ENTITY, RANDOLPH HOSPITAL, INC. SAID OFFICERS ARE ALLOWED REIMBURSEMENTS FOR HEALTH AND/OR SOCIAL CLUB DUES. RANDOLPH HOSPITAL, INC. 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. 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. RANDOLPH HOSPITAL USES THE FOLLOWING METHODS: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACTS - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE SCHEDULE J, PART II: WE ARE REQUIRED TO REPORT COMPENSATION OF KEY INDIVIDUALS THAT WORK FOR AND ARE PAID BY A RELATED ORGANIZATION. COMPENSATION REPORTED ON THIS SCHEDULE DOES NOT NECESSARILY MEAN 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 OCCURRING 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 SOLD MEMBER, (5) TO APPROVE ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS 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 RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT FROM MANAGEMENT. THE 990 WAS REVIEWED BY THE ORGANIZATION'S BOARD OF DIRECTORS. ANYONE NOT IN ATTENDANCE DURING THE MEETING WAS PROVIDED A COPY AND INVITED TO SUBMIT QUESTIONS. FOLLOWING THE REVIEW, THE RETURN WAS FILED WITH THE IRS. 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 ALL CURRENT EMPLOYEES ARE REQUIRED TO TAKE ANNUAL EDUCATION ON COMPLIANCE WITH THE POLICY. THERE IS A MONTHLY CORPORATE COMPLIANCE MEETING TO UPDATE KEY INDIVIDUALS ON NEW ISSUES AND NEW INFORMATION REGARDING CORPORATE COMPLIANCE. THE BOARD OF DIRECTORS IS REQUIRED ANNUALLY TO READ, SIGN, AND REMIT A COPY OF THE POLICY TO THE BOARD CHAIR. ALL BOARD MEMBERS ARE AWARE OF THE POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS ACQUIRES OUTSIDE INFORMATION USED TO DETERMINE EXECTUIVE SALARIES. 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 VII, LINE 1A 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: EQUITY TRANSFER TO RELATED PARTY 1,275,639. TOTAL TO FORM 990, PART XI, LINE 5: 1,275,639. 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 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 SPECIALTY GROUP PRACTICE 364 WHITE OAK STREET ASHEBORO NC 27204 113827203 HEALTHCARE NC 501(C)(3) LINE 9 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 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 1 0 1