2013-11-13T09:05:11-06:00 2012-12-31 366055558 Grant Thornton LLP 1717 Main Street Suite 1500 Dallas TX 75201 990 2012-01-01 750800628 Children's Medical Center of Dallas CHIL 2144567000 1935 Medical District Drive Dallas TX 75235 Jerry Lee 2144567000 2013-11-13 1 Kimberly Temple CPA P00669176 2145612300 2012 2016-03-07 17:11:31Z Christopher J Durovich 1935 Medical District Dr Dallas TX 75235 1064980296 0 X www.childrens.com X 1986 TX Dedicated to making life better for children 19 18 6693 6179 0 0 22203306 28808277 986650594 984976635 34066370 24210891 17729771 26856715 1060650041 1064852518 30500 21500 0 0 472214736 517642683 0 0 0 429496069 407504890 901741305 925169073 158908736 139683445 1913488935 2116928959 690388149 693568732 1223100786 1423360227 X Children's Medical Center of Dallas is dedicated to making life better for children. Children's is committed to carry out this mission through adherence to four guiding principles: quality care; research & innovation; education & advocacy; and excellence & accountability. 0 0 644451096 21500 1008146372 Consistent with its charitable mission, Children's maintains a policy of accepting all patients within its primary service area regardless of ability to pay. The local service regions stretch from the Oklahoma border south to Waco and from Parker County (west of Ft. Worth) east to Wood County. For the fiscal year ended December 31, 2012, Children's absorbed $157 million of uncompensated healthcare services as a result of this open-door charitable policy. Children's participates in applicable government sponsored entitlement programs. For the year ended December 31, 2012, approximately 58% of Children's gross revenue is attributable to patients enrolled in state Medicaid programs.During 2012, Children's served approximately 150,000 patients. Children's had 46,141 patient admissions resulting in 102,899 patient days, and provided services in 540,082 outpatient visits. In addition, the hospital staff performed 17,820 day surgeries. In recognizing its mission to the community, Children's participates in the Medicaid, Medicare, Children's Health Insurance Program (CHIP), Chronically Ill and Disabled Children (CIDC), and Champus government programs. Under an agreement with the Dallas County Hospital District, Children's provides services to the indigent children of Dallas County. 4291107 6713012 Children's is the primary pediatric teaching hospital for the University of Texas Southwestern Medical School at Dallas and has the fifth largest pediatric training program in the country. Currently, there are 100 pediatric residents, three chief residents and approximately 120 pediatric subspecialty residents and fellows enrolled in this training program. Children's offers fellowships/residencies in these pediatric subspecialties, as well as internships and fellowships/residencies in nursing, dentistry, allied health, social sciences and religious studies. In addition to internship and fellowship programs, many students representing a variety of health care professions come to Children's to complete a pediatric rotation as a requisite of their training. 2529290 3963956 Through Children's affiliation with UTSW Medical Center, ongoing research is promoted in many different clinical areas of the hospital. The end goal of this research is the development of newer, more effective diagnostic & treatment methods to meet the health care needs of children. All research involving human subjects is approved by the Institutional Review Board at UTSW. Joint areas of research efforts between UTSW's Department of Pediatrics & Children's are: critical care, immunology, gastroenterology, emergency medicine, radiology, nutrition, endocrinology, psychiatry, cardiology, pharmacology, nephrology, neurology, pulmonology, rheumatology, infectious diseases & hematology/oncology. Many of these clinical studies have been published in medical journals & presented to professional health care societies. 651271493 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 1359 0 1 6693 1 0 0 0 0 0 0 0 0 0 0 X 19 18 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X Stephanie K Smith 2144567000 1935 Medical District Drive Dallas TX 75235 X Christopher J Durovich 60.00 0.00 X X 1975308 0 85059 Robert Chereck 1.00 0.00 X X 0 0 0 Richie L Butler 1.00 0.00 X 0 0 0 Ann Goddard Corrigan 1.00 0.00 X 0 0 0 Michael Dardick 1.00 0.00 X 0 0 0 Gregg L Engles 1.00 0.00 X 0 0 0 Robert A Estrada 1.00 0.00 X 0 0 0 Ed Heffernan 2.00 0.00 X 0 0 0 Richard Knight Jr 1.00 0.00 X 0 0 0 Tracey Kozmetsky 1.00 0.00 X 0 0 0 Charles Matthews Jr 1.00 0.00 X 0 0 0 Thomas A Montgomery 1.00 0.00 X 0 0 0 Anne Motsenbocker 1.00 0.00 X 0 0 0 Connie O'Neill 1.00 0.00 X 0 0 0 Barbara Stuart 1.00 0.00 X 0 0 0 Gifford Touchstone 1.00 0.00 X 0 0 0 John F Young 1.00 0.00 X 0 0 0 David Biegler 1.00 0.00 X 0 0 0 Steven M Gruber 1.00 0.00 X 0 0 0 Michele Chulick 55.00 0.00 X 180740 0 0 James Herring 55.00 0.00 X 586754 0 155791 Douglas G Hock 55.00 0.00 X 802982 0 24605 Julio Perez-Fontan MD 55.00 0.00 X 480000 0 0 Peter W Roberts 55.00 0.00 X 558786 0 26025 David G Biggerstaff 55.00 0.00 X 416376 0 22079 Ray R Dziesinski 55.00 0.00 X 722122 0 20019 Michael Frick 55.00 0.00 X 160175 0 0 John P Kline 55.00 0.00 X 698016 0 15009 Regina M Coggins 55.00 0.00 X 466685 0 18606 Trent C Smith 55.00 0.00 X 515080 0 23859 Patricia U Winning 55.00 0.00 X 741612 0 45224 Pamela K Arora 50.00 0.00 X 567847 0 16953 Kim S Besse 50.00 0.00 X 375671 0 23586 Daniel T Carney 50.00 0.00 X 361056 0 14298 Paul Hain MD 50.00 0.00 X 288310 0 0 Keri Kaiser 50.00 0.00 X 42888 0 278 Jerry Lee 50.00 0.00 X 291531 0 13938 Justin J Lombardo 50.00 0.00 X 435967 0 16118 Mitchell Mulvehill 50.00 0.00 X 172285 0 17332 Paul M Musgrave 50.00 0.00 X 308859 0 13601 Ronald C Skillens 50.00 0.00 X 293004 0 24187 Stephanie Slaughter 50.00 0.00 X 85524 0 1779 Mary E Stowe RN 50.00 0.00 X 456849 0 21559 Jeffery J Vawrinek 50.00 0.00 X 252742 0 8274 Vanessa U Walls 50.00 0.00 X 258608 0 25427 Thomas M Zellers MD 50.00 0.00 X 150000 0 0 Jean Ann Larson 50.00 0.00 X 415218 0 7055 Elizabeth Field Mackay 50.00 0.00 X 307354 0 3761 Stephanie K Smith 40.00 0.00 X 102713 0 744 Christopher Menzies MD 40.00 0.00 X 276582 0 618 Deborah Sheppard 40.00 0.00 X 213271 0 3262 Karissa Luckett 40.00 0.00 X 235088 0 660 Michele Whitsett 50.00 0.00 X 210425 0 12073 Teresa Egan 40.00 0.00 X 289018 0 886 14695446 0 662665 612 0 1 0 UTSW HI 108 5323 Harry Hines Blvd Dallas TX 753908886 Phys & Medical Svcs 62782601 DPR Construction 1450 Veterans Blvd Redwood City CA 94063 Construction Services 11762831 Comforce Technical Services PO Box 31001-0893 Pasadena CA 911100893 Staffing/Consulting Svcs 9992876 JE Dunn Construction Co 16000 Dallas Pkwy 500 Dallas TX 75248 Construction Services 9463970 Medline Industries Inc 9303 Stoneview Dr Dallas TX 75237 Medical Supplies 9254657 366 21467207 7341070 20000 28808277 Inpatient Revenue 622110 1213597852 1213597852 Outpatient Revenue 621400 875488236 875488236 Day Surgery Revenue 621400 177069052 177069052 Prov for Dbtful Accts 622110 -41052204 -41052204 Deductions from Rev. 622110 -1240126301 -1240126301 984976635 24338669 24338669 169677 0 169677 169677 169677 127778 -127778 -127778 -127778 Other Med Svc Revenue 622110 22201785 22201785 Dietary Revenue 621990 4296717 4296717 Vending Revenue 454210 188536 188536 26687038 1064852518 1011475137 0 24569104 X 21500 21500 15077896 3686392 11391504 384608400 306024318 78584082 44100469 34172769 9927700 45841824 34229422 11612402 28014094 21707687 6306407 5009445 1229862 3779583 1994230 1994230 488974 488974 116167757 104064814 12102943 15284302 500723 14783579 6087690 2282459 3805231 21295495 1341162 19954333 37235905 6573624 30662281 1963703 853308 1110395 2660755 869098 1791657 25071439 25071439 56537710 39799643 16738067 7796437 144612 7651825 Med./Surgical Supplies 86100520 85133717 966803 Consulting & Prof Fees 13070026 1261271 11808755 Dietary and Food Costs 4875259 4476765 398494 Collection Fees 1688553 1688553 4176690 2898347 1278343 925169073 651271493 273897580 0 276459420 221398992 60174111 185907889 107673297 131246984 9440176 10205126 11473098 10557487 1200159273 499029066 688391209 701130207 453558956 502599817 306318668 353882457 1913488935 2116928959 147005857 160024344 12739 16827 387391709 386575772 10793392 132489 145184452 146819300 690388149 693568732 X 956004433 1125704796 216997465 224474963 50098888 73180468 1223100786 1423360227 1913488935 2116928959 X 139683445 26107582 34468414 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 107614 107614 0 Explanation of Lobbying Activities: Part II-B, Line 1: In 2012, CMCD paid membership dues to organizations in which a portion of the membership dues were related to lobbying activities. NACH (National Association of Children's Hospitals), AHA (American Hospital Association), THA (Texas Hospital Association), TAVH (Texas Association of Voluntary Hospitals), THOT (Teaching Hospitals of Texas), and CHAT (Children's Hospital Association of Texas) identifed a portion of their membership dues as being related to lobbying activities. Lobbying percentages were identified by said organizations and applied to 2012 membership dues. 39925662 39925662 705921314 205574874 500346440 9237351 6414537 2822814 379220896 287039655 92181241 65854050 65854050 701130207 Net Assets of Foundation 297628187 Other Assets 19714292 LT Advances to Affiliates 36539978 353882457 UTSW Phys Guarantees 7334442 Retirement Plan Accr 128882263 Rsv for Professional Liab 8216291 Other Liabilities 2386304 146819300 Part X, Line 2: In 2012 Children's Medical Center of Dallas was not required to have a FIN48 footnote disclosure. 1 1 X 1 X 1 X 1 1 0 1 1 24495391 367819 24127572 0.02830 493407738 442592162 50815576 0.05970 64890158 51808495 13081663 0.01540 582793287 494768476 88024811 0.10340 7717192 498135 7219057 0.00850 31349244 1884554 29464690 0.03460 0 0 0.00000 5819683 0 5819683 0.00680 1952946 123329 1829617 0.00210 46839065 2506018 44333047 0.05200 629632352 497274494 132357858 0.15540 304823 304823 0.00040 304823 304823 0.00040 1 14093603 5145891 6901413 1475426 5425987 X 1 1 1 NONE 2 1 Children's Medical Center of Dallas

1935 Medical District Drive Dallas TX 75235

X X X X X Both Dallas and Legacy campuses share a License, 2 Children's Medical Center of Legacy

7601 Preston Road Plano TX 75024

X X X X X EIN, and MCR provider number. _ Children's Medical Center of Dallas 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X 0 0 Children's Medical Center of Legacy 2 1 1 200.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X 0 0 Part I, Line 3c: Children's uses the Federal Poverty Guidelines to determine eligibility for low income individuals. 200% of the Federal Poverty Guidelines is used for 100% charity adjustment, and 201% to 400% of the Federal Poverty Guidelines is used for a sliding scale adjustment. Part I, Line 6a: Children's Community Benefit Report is prepared by our Public Relations department with collaboration from numerous departments within the hospital. Part I, Line 7: Total expenses for Schedule H purposes are calculated using Worksheet 2, Ratio of Patient Care Cost to Charges, from the Form 990 Schedule H guidelines. Part I, L7 Col(f): Children's recorded $41,052,204 in bad debt expense for the year. The bad debt expense recorded was excluded from the calculation of community benefit expense. Part II: Children's is passionate about maintaining a vocal presence in legislative affairs on the local, state and federal levels and is at the forefront of governmental efforts that affect the community at large, from booster seat and car safety measures to critical funding initiatives. Additionally, Children's collaborates extensively with our partners in coalitions such as the Children's Hospital Association of Texas (CHAT) and the Texas Hospital Association (THA) at the state level, as well as the Children's Hospital Association (formerly the National Association of Children's Hospitals and Related Institutions). Children's President and Chief Executive Officer also serves on the Board of Trustees for the American Hospital Association. Through these affiliations, Children's is better able to advocate the development of an effective, comprehensive and appropriately funded children's health care system in Texas and across the country. Part III, Line 4: and Part III, Line 2 and 3: The following is the footnote disclosure related to the Allowance for Doubtful Accounts, provided with Children's Audited Financial Statements. Children's maintains allowances for doubtful accounts to reserve for potential write-offs relating to a patient's inability to make payments on an account. Accounts are written off when collection efforts have been exhausted. Childrens routinely monitors its accounts receivable balances and utilizes historical collection experience to support the basis for its estimates of the provision for doubtful accounts.Children's uses Worksheet 2 from the Form 990 Schedule H instructions to calculate the bad debt expense and ratio of patient care cost to charges attributable to community benefits. Part III, Line 8: Children's uses Worksheet A from the As Filed Medicare Cost Report and the IRS Schedule H Instructions to determine Medicare allowable costs. Part III, Line 9b: and Part VI, Line 3: Children's has written debt collection policies which identify collection practices to be followed. The collection practices determine for what financial assistance a patient qualifies, and if a patient does not qualify for financial assistance, Children's also has written collection practices to be followed to determine if a patient qualifies for charity care. As part of the collection practice, Childrens' financial counselors review with the patient and their family the various state and federal programs available to them. Children's Medical Center of Dallas Part V, Section B, Line 10: Children's Medical Center of Dallas uses the Federal Poverty Guidelines to determine eligibility for low income individuals. 200% of the Federal Poverty Guidelines is used for 100% charity adjustment, and 201% to 400% of the Federal Poverty Guidelines is used for a sliding scale adjustment. Children's Medical Center of Legacy Part V, Section B, Line 10: Children's Medical Center of Legacy uses the Federal Poverty Guidelines to determine eligibility for low income individuals. 200% of the Federal Poverty Guidelines is used for 100% charity adjustment, and 201% to 400% of the Federal Poverty Guidelines is used for a sliding scale adjustment. Children's Medical Center of Dallas Part V, Section B, Line 12h: Children's Medical Center of Dallas uses various documents and forms to verify income and expenses when determining the eligibilty for financial assistance of a patient and their family. These documents include, but are not limited to, W2 Form, wage and earning statement, pay check remittance, worker's compensation, unemployment compensation determination letters, income tax returns, statement from employer, bank statements, copy of checks, documents of sources of income, telephone verification of gross income with the employer, proof of participation in government assistance programs such as Medicaid, signed affadavit or attestation by patient, and veterans benefit statement. Children's Medical Center of Legacy Part V, Section B, Line 12h: Children's Medical Center of Legacy uses various documents and forms to verify income and expenses when determining the eligibilty for financial assistance of a patient and their family. These documents include, but are not limited to, W2 Form, wage and earning statement, pay check remittance, worker's compensation, unemployment compensation determination letters, income tax returns, statement from employer, bank statements, copy of checks, documents of sources of income, telephone verification of gross income with the employer, proof of participation in government assistance programs such as Medicaid, signed affadavit or attestation by patient, and veterans benefit statement. Children's Medical Center of Dallas Part V, Section B, Line 14g: In addition to ensuring that the Children's charity care criteria is posted prominently and continuously in common entry points of the facility, a Director of Patient Financial Service ensures that the Children's charity care criteria is published annually in a local newspaper of general circulation in the county. Children's Medical Center of Legacy Part V, Section B, Line 14g: In addition to ensuring that the Children's charity care criteria is posted prominently and continuously in common entry points of the facility, a Director of Patient Financial Service ensures that the Children's charity care criteria is published annually in a local newspaper of general circulation in the county. Children's Medical Center of Dallas Part V, Section B, Line 20d: Children's Medical Center of Dallas determines the maximum amount that can be charged to individuals eligible for financial assistance for emergency or other medically necessary care by calculating the average commercial and government payor amounts received by Children's. Children's Medical Center of Legacy Part V, Section B, Line 20d: Children's Medical Center of Legacy determines the maximum amount that can be charged to individuals eligible for financial assistance for emergency or other medically necessary care by calculating the average commercial and government payor amounts received by Children's. Part VI, Line 2: Community Needs AssessmentSince 1994, Children's has produced a comprehensive quality-of-life report on area children, Beyond ABC: Growing Up in Dallas County. Beginning in 2008, a separate study has been published to focus on youth in Collin County as well. These biennial reports provide 10 years of trended data on the many factors facing children in our community. Beyond ABC analyzes more than 50 indicators of well-being with respect to health, education, safety and security for the more than 900,000 children that call those areas home.Children's has taken on the task of preparing Beyond ABC and distributing it to child advocates, service agencies, community leaders and lawmakers because of the presence the hospital holds in the community. In turn, these community leaders and organizations as well as Children's use the report to help determine how best to employ their resources each year. Part VI, Line 4: Children's Medical Center of Dallas is well known for bringing exceptional medical and surgical care to the children of North Texas. Through community events, child-specific initiatives and organizational affiliations, the hospital invests in prevention, research, education, clinical excellence and advocacy to benefit all children.Children's devotes itself solely to caring for the complex medical needs of children. Children's provides patient care ranging from simple eye exams to specialized treatment in areas such as heart disease, hematology-oncology and cystic fibrosis. In addition, Children's is a major pediatric kidney, liver, intestine and heart transplant center. Through its established injury prevention, advocacy program and disease management programs, the hospital works diligently to educate the community so that no child has to ever to come through our doors.Licensed for 559 beds and supporting more than 50 specialty and subspecialty programs, Children's was the state's first pediatric hospital with a designated Level I Trauma center. To better serve the region's growing pediatric population Children's Medical Center at Legacy, a second full-service campus opened in 2008 in Plano. Children's is a private, not-for-profit hospital system that does not receive local tax dollars to offer the care we provide. We are philanthropically supported in our efforts to provide care for every child who comes to us, regardless of their family's ability to pay. Donors also play a significant part in our ability to conduct research, education and advocacy.Annually, we attend to approximately 150,000 patients who represent over 570,000 individual visits. But that doesn't stop us from offering an elite level of individual care and attention to each family. As the primary pediatric teaching facility for the UT Southwestern Medical Center at Dallas, ("UTSW") we are the only full-service, academic-affiliated pediatric hospital in North Texas. Through our academic affiliation, the Children's medical staff conducts research that is instrumental in developing treatments, therapies, and greater understanding of pediatric diseases and trains more than 200 pediatric residents and fellows annually.Because of that, access to leading-edge research and treatments gives the children of North Texas and far beyond the most innovative options available. Children's also has affiliations with more than 100 other nursing and allied health educational programs across the country, providing our professionals access to curricula at other leading academic institutions. With more than 800 physicians on the medical staff, Children's brings together some of the world's top minds to provide the highest level of pediatric healthcare to North Texas and beyond.A voice for childrenAt Children's we consider it a privilege and responsibility to serve as ardent advocates for children.We work tenaciously to influence health and public policies. Through a combination of programmatic initiatives, organizational affiliations and community events, Children's spreads its influence into the region and provides area children much-needed access to a better quality of life. Whether that means establishing programs to increase services to the area's underserved children or fostering partnerships with existing organizations, Children's is committed to connecting families to the services they need.Children First! Collin County CoalitionChildren's is the founding member and sponsor of the Children First! Collin County Coalition, a nonpartisan alliance of more than 80 non-profit organizations. The coalition works to improve the quality of life of children through the development of initiatives related to public policy, advocacy, public awareness and community programs. The coalition's five work groups focus on economic security, education, family strengthening, health and safety. Community Outreach Through the efforts of the Community Relations staff at Children's, more area children who are eligible for Medicaid or the Children's Health Insurance Program (CHIP) are receiving coverage. Almost 18 percent of the children living in Dallas County are uninsured. Lack of health insurance leads to poorer health in childhood, greater rates of avoidable hospitalizations and higher childhood mortality. Uninsured children are 8 times more likely to have delayed care and 12 times more likely to have an unmet medical need than children with private insurance.Children's is committed to helping families obtain health insurance, an important factor in the health and well-being for our entire community. Children's has a vision to help address the shortage of primary pediatric medical care for families with limited resources.Dallas CHIP CoalitionChildren's founded and sponsors the Dallas Children's Health Insurance Program Coalition, an alliance of more than 90 organizations focused on helping families of uninsured children apply for CHIP or Medicaid. In addition, the coalition provides community leadership on public policy issues that affect the crisis of uninsured children in our community. MEDICAID/CHIP Outreach EventsAnnually, Children's coordinates two large community outreach events targeting the families of uninsured children. Working with the Dallas Children's Health Insurance Program Coalition, these events are promoted through school flyers and the media. Since 2005, these events have helped more than 12,000 families apply for coverage for more than 24,000 children. The coalition has trained more than 250 volunteers to assist families with applications for CHIP or Medicaid. School Based Medicaid/Chip Outreach Children's outreach team conducts Medicaid/Children's Health Insurance Program outreach at 8 area school districts with a combined enrollment of more than 350,000. Each student's family receives at least four communications during a school year with information on the importance of health insurance and the tools to apply for CHIP/Medicaid. In 10 years, Children's has trained more than 2,500 school staff and volunteers, completed more than 60,000 applications for Medicaid/CHIP and participated in over 700 special events. Children's serves as a liasion with the state for families who could not successfully navigate the state's eligibility system. Part VI, Line 5: Children's mission is to make life better for children. We consider it our privilege and our responsibility to serve as ardent advocates for kids in Texas and across the country. To that end, we work tirelessly to ensure that children's voices are heard and that their needs are met. Our efforts to influence public policies that impact children's health are comprehensive and ongoing. Through programmatic initiatives, organizational partnerships and community events, Children's spreads its influence throughout the region and provides area children with much-needed access to a better quality of life. Whether that means establishing programs to increase services to the area's underserved children or fostering partnerships with existing organizations, Children's is committed to connecting families to the services they need. Tackling an epidemic Texas ranks sixth in the nation for obesity in 10 to 17 year-olds, and the problem is even more pressing in Dallas County. More than one-third (36.1 percent) of Dallas Independent School District high-school students are obese or overweight, almost double the national average, according to the Department of State Health Services. In 2008, only one in five Dallas ISD third-graders passed the Texas-mandated school Fitnessgram assessment, compared to about one in three statewide. At Children's, we provide services to 7,500 patients each year with diagnoses that research shows to be obesity-related. These include cardiology, endocrine, gastrointestinal, pulmonary and psychiatric diagnoses. Dental OutreachAlthough effective methods exist to prevent tooth decay, cavities remain the most prevalent chronic condition among children-five times more common than asthma and seven times more common than hay fever. Inpartnership with UT Southwestern Medical Center at Dallas, a grant has been obtained so that children from the continuity clinics and ARCH (At-Risk Children) clinic who are identified as at-risk are now provided oral health education and fluoride varnish every three months to reduce their risk of cavities.Children's websiteOur hospital web site, www.childrens.com, empowers parents with the latest information about childhood illnesses, prevention, treatment and services available at the hospital. More than 1,300 common pediatric topics are addressed on the Web site. Also available are interactive guides promoting healthy living that target both children and their parents. The site also offers a free subscription to a monthly electronic newsletter that connects our community to the amazing things that take place at Children's every day.Reaching out to support the families of our communities is at the heart of the Children's mission. The challenge of ensuring the safety and well-being of all children is a driving force for the hospital, its employees and its medical staff. Assessing how many lives our services touch requires a look into our community, where the Children's influence has impact far beyond the hospital's walls.Disease Management and WellnessThe Disease Management and Wellness Department at Children's improves quality of life and decreases the use of healthcare services through education and pro-active self-management. Children's has seven disease-specific certifications, the most of any pediatric center in the United States. The programs offer access to evidence-based care and support that is needed for the management of conditions like asthma, diabetes and obesity.The disease management initiative is part of the hospital's ongoingefforts to reduce emergency department use, decrease admissions, curtail healthcare costs and ultimately, improve the quality of life for children with chronic conditions. Each program provides a family-centered environment that focuses on providing quality care to patients and overall increased disease awareness. Coaching coaches, athletes and parentsChildren's is committed to educating coaches, parents and young athletes on the importance of sports injury prevention. The hospital has a presence at dozens of coaches' clinics each year at facilities such as the Plano Sports Authority and Dallas Baseball Academy of Texas. During the clinics, Children's provides sports-specific injury-prevention cards and clipboards to thousands of coaches each year. So far, we have impacted the health and safety of 400,000 young athletes. Children's has also worked with companies such as Kohl's Corporation and their Sports Health and Wellness Outreach Program, to further support community outreach efforts. Spreading a message of water safetyDrowning is the second-leading cause of unintentional injury-related deaths among American children ages 1 to 14. The Know Before You Go Program spreads the message that every drowning is preventable when parents take appropriate precautions. The program includes distributing water safety materials, providing demonstrations on proper water rescue techniques and the use and proper fit of Coast Guard approved flotation devices. Working to reduce preventable injuriesMore than a decade ago, Children's formed the Safe Kids Dallas Area Coalition - the local chapter of Safe Kids Worldwide - to prevent childhood injuries. Traumatic injuries are the leading cause of death in Texas in children ages 1 to 14, and preventing these injuries is imperative at Children's - the first Level I trauma center in Texas (and one of only two in the state) that is solely dedicated to treating pediatric patients. Since 2002, the number of patients hospitalized because of motor vehicle crashes has steadily risen. Children's Injury Prevention Program has expanded its outreach efforts accordingly to bring car seat safety education and installation services to the community in an effort to reduce the number of children injured in car crashes. A specific initiative within the Safe Kids Dallas program is our car-seat safety inspection project. The project offers child safety-seat inspections by certified car seat technicians at Children's Dallas and Legacy campus so parents can learn to buckle up their children appropriately. Part VI, Line 6: Children's is not part of an affiliated health care system.Part VI, Line 7: Children's files a Community Benefit Plan with the State of Texas as required by Senate Bill 427. 1 May Smith Scholars Program 1 4500 Women's Auxiliary Education Assistance Program 10 11000 University of Texas at Arlington 1 5000 James J. Farnsworth Health Careers Scholarship 1 1000 May Smith Scholars Program The May Smith Scholars program provides both financial assistance and practical clinical experience for students interested in pediatric nursing. The scholarship program is named for May Forster Smith, who began an open-air clinic for infants in 1913 in Dallas. Sophomore and junior undergraduate students are eligible to apply to receive $5,000 each year for up to two years. Recipients of the scholarships must work at Children's as nurse externs for at least 400 hours during their undergraduate program. After graduation, recipients will be offered employment as registered nurses in one of the Children's Nurse Internship Tracts: Critical Care, Emergency, General Pediatrics, Hematology-Oncology, or Perioperative Services. Women's Auxiliary Educational Assistance Program The Women's Auxiliary to Children's offers educational support to nursing and allied health students who are registered for or currently enrolled in an accredited program through the Educational Assistance program for Nursing and Allied Health Students. Students who qualify may receive up to $1,000 per semester. Educational assistance is granted and paid on a per-semester basis. Students or prospective students of accredited nursing or allied health programs may apply if they: 1.) Are junior or senior level students enrolled full or part time in an accredited undergraduate or graduate nursing program. 2.) Maintain an overall grade point average of 3.0 on a 4.0 scale, or cumulative 3.0 prior to being accepted into an accredited program. Students are asked to sign agreements to work full time for 12 months at Children's for each academic year they receive education assistance or 6 months for each semester. If the students are offered employment with Children's but decline the offer, they will be obligated to repay the full amount plus interest calculated at the current prime interest rate at the time the offer is declined. Pediatric Post-Masters Certificate Program The University of Texas at Arlington School of Nursing and Children's Medical Center Dallas offer an Acute Care Pediatric Nurse Practitioner Post-Masters Certificate Program that consists of 31 credit hours. The program prepares students to serve in advanced practice leadership roles with infants, children and adolescents who have acute and chronic health care needs. Requirements include: an MSN from an NLN-accredited program 3.0 GPA on a 4.0 scale for the MSN, Registered Nurse Licensure in Texas, Physical Assessment content within the past three years, and Two years' experience in Pediatric Acute Care nursing recommended. James J. Farnsworth Health Career Scholarship Program The James J. Farnsworth Health Career Scholarship offers educational support to students planning careers in pediatric healthcare. The scholarship is named in honor of James J. Farnsworth and was established from gifts to endowments made in tribute to Mr. Farnsworth by his friends and colleagues. Mr. Farnsworth served as president of Children's Medical Center Dallas for more than 30 years and was a fellow in the College of Healthcare Executives. Junior or senior undergraduate students or graduate students planning a career in pediatric healthcare may apply. Preference will be given to students who fall into the following categories: Former patients of Children's Current full or part-time employees. Former or current volunteers at Children's. Parent is employed at Children's. Parent is a volunteer at Children's. Student demonstrating strong academic achievement and financial needs. The James J. Farnsworth Health Career Scholarship is a forgivable loan, meaning students do not owe any service time to Children's Medical Center of Dallas after receiving the scholarship. X X X X 1 1 X X X X 1 1 0 0 0 0 0 1 0 Christopher J Durovich 893847 0 934334 0 147127 0 60405 0 24653 0 2060366 0 514968 0 Michele Chulick 149740 0 30000 0 1000 0 0 0 0 0 180740 0 0 0 James Herring 196876 0 150796 0 239082 0 155767 0 24 0 742545 0 0 0 Douglas G Hock 436013 0 321814 0 45155 0 14018 0 10587 0 827587 0 183814 0 Julio Perez-Fontan MD 480000 0 0 0 0 0 0 0 0 0 480000 0 0 0 Peter W Roberts 437735 0 100000 0 21051 0 10000 0 16025 0 584811 0 0 0 David G Biggerstaff 244875 0 144323 0 27178 0 7355 0 14725 0 438456 0 104889 0 Ray R Dziesinski 383861 0 287925 0 50336 0 13379 0 6639 0 742140 0 173018 0 Michael Frick 105897 0 20000 0 34278 0 0 0 0 0 160175 0 0 0 John P Kline 256157 0 237295 0 204564 0 1666 0 13343 0 713025 0 64257 0 Regina M Coggins 299144 0 119574 0 47967 0 7550 0 11056 0 485291 0 39394 0 Trent C Smith 324053 0 143091 0 47936 0 11313 0 12547 0 538940 0 44948 0 Patricia U Winning 379696 0 306500 0 55416 0 36620 0 8604 0 786836 0 191137 0 Pamela K Arora 328058 0 193780 0 46009 0 13076 0 3877 0 584800 0 150114 0 Kim S Besse 251214 0 76283 0 48174 0 9699 0 13886 0 399256 0 44928 0 Daniel T Carney 263253 0 74024 0 23779 0 10252 0 4047 0 375355 0 22082 0 Paul Hain MD 288310 0 0 0 0 0 0 0 0 0 288310 0 0 0 Jerry Lee 247110 0 40688 0 3733 0 9529 0 4410 0 305470 0 0 0 Justin J Lombardo 286381 0 80746 0 68840 0 12364 0 3754 0 452085 0 65690 0 Mitchell Mulvehill 155400 0 15000 0 1885 0 4880 0 12452 0 189617 0 0 0 Paul M Musgrave 241272 0 65464 0 2123 0 10000 0 3601 0 322460 0 0 0 Ronald C Skillens 195419 0 58094 0 39491 0 9781 0 14406 0 317191 0 36121 0 Mary E Stowe RN 264730 0 157674 0 34445 0 13214 0 8345 0 478408 0 113296 0 Jeffery J Vawrinek 224120 0 27103 0 1519 0 8274 0 0 0 261016 0 0 0 Vanessa U Walls 222176 0 34149 0 2283 0 9728 0 15699 0 284035 0 0 0 Jean Ann Larson 104306 0 57398 0 253514 0 3703 0 3351 0 422272 0 13912 0 Elizabeth Field Mackay 44724 0 51630 0 211000 0 2218 0 1543 0 311115 0 13608 0 Christopher Menzies MD 248998 0 22130 0 5454 0 0 0 618 0 277200 0 0 0 Deborah Sheppard 78453 0 18313 0 116505 0 0 0 3262 0 216533 0 0 0 Karissa Luckett 122016 0 17952 0 95120 0 0 0 660 0 235748 0 0 0 Michele Whitsett 186135 0 20580 0 3710 0 0 0 12073 0 222498 0 0 0 Teresa Egan 189306 0 55000 0 44712 0 0 0 886 0 289904 0 0 0 Part I, Line 1a * Children's written policy on business and educational travel prohibits first class travel except when approved in advance by the CEO or by the Board Chair. * Companion travel is prohibited except when it is deemed to further Children's business activities and must be approved in advance by the CEO or Board Chair. Approved companion travel is included as taxable income in 2012 for Christopher J Durovich. * Compensation is grossed up in limited circumstances with prior approval of the appropriate board committee. Approved one-time, grossed up compensation has been included as 2012 taxable income for Christopher J Durovich, Peter W Roberts, Michael Frick. * In an effort to continue to attract quality leadership, Children's provides temporary housing allowances as a taxable benefit to executives and other key employees relocating to Dallas. Part I, Lines 4a-b Severance Payment and Non-Qualified Retirement Plan: * Severance - Jean Ann Larson - $195,750 * Severance - Elizabeth Field MacKay - $168,250 * Severance - Karissa Luckett - $65,585 * Severance - Deborah Sheppard - $96,251 * Retirement Income Restoration Plan - James Herring received $153,267 as taxable income from the Retirement Income Restoration Plan as he is over the age of 65. Elizabeth Field MacKay received $1,073 as taxable income from the Retirement Income Restoration Plan, as a result of a Qualifying Termination under the severance plan. Additional employees who participate in the Retirement Income Restoration Plan are Christopher J Durovich, Douglas G Hock, Mary E Stowe, and Patricia U Winning. * Savings Restoration Plan - James Herring received $991 as taxable income from the Savings Restoration Plan as he is over the age of 65. John P Kline received $44,386 as taxable income from the Savings Restoration Plan, as a result of a Qualifying Termination under the severance plan. Jean Ann Larson received $239 as taxable income from the Savings Restoration Plan, as a result of a Qualifying Termination under the severance plan. Additional employees who participate in the Savings Restoration Plan are Christopher J Durovich, Douglas G Hock, Mary E Stowe, Patricia U Winning, Pamela Arora, Kimberly Besse, David G Biggerstaff, Daniel Carney, Regina M Coggins, Ray R Dziesinski, Jerry Lee, Justin Lombardo, Paul Musgrave, Peter Roberts, Ronald Skillens, Trent C Smith, Jeffrey Vawrinek, and Vanessa Walls. Part I, Line 7 Non-Fixed Payments - The Human Resources Committee of the Board of Directors retains the authority to adjust annual payout percentages solely at their discretion. A N Central Tx Hlth Fac Dev Corp Hosp 521304502 65854RAL4 2009-07-01 193697772 Reimburse Construction Cost 0 0 0 B N Central Tx Hlth Fac Dev Corp Hosp 521304502 65854RBD1 2012-08-15 183637368 Refund Series 2002 Bonds 0 0 0 A 193697772 2819039 190566160 312573 2009 0 0 0 1 B 183637368 2020125 1 0 1 1 A 0 0 1 0 0 0.00210 0.00210 0 0 1 A 0 0 0 0 0 0 0 0 1 B 0 0 0 0 0 0 0 0 1 A 1 B 1 Schedule K, Part I, Line B Series 2012 Bonds were issued for the purpose of currently refunding the Issuer's Hospital Revenue Bonds (Children's Medical Center of Dallas Project) Series 2002 (original issue date prior to December 31, 2002). Form 990, Part VI, Section A, line 1 Children's Board membership includes four ex officio non voting members. Form 990, Part VI, Section A, line 1 An Executive Committee, whose membership must be approved by the Board of Directors of the Corporation, may be appointed annually. The Executive Committee shall have full power in the intervals between the meetings of the Board to perform any and all acts relating to the affairs of the Corporation and to exercise any and all powers of the Board in the management and direction of the business and conduct of the Corporation, subject to any limitations provided by applicable law, the Certificate of Formation of the Corporation or the Bylaws. It may meet or conduct its business in any fashion or by any means applicable to the meetings of the Board of Directors and shall keep a record of its proceedings and report the same to the Board at each succeeding meeting of the Board. Form 990, Part VI, Section A, line 6 Children's Health Services of Texas ("CHST"), a Texas non-profit corporation, is the sole member of the corporation. Form 990, Part VI, Section A, line 7a CHST elects all members of the organization's Board of Directors. Form 990, Part VI, Section A, line 7b A list of decisions requiring approval by the member is as follows: a) Any change in the mission or purpose of the Corporation; b) Any amendment to the Articles of Incorporation or Bylaws of the Corporation; c) Any addition of new Members; d) Any purchase or acquisition, sale, gift, lease, disposition of, mortgage or other encumbrance of any property, real, personal, or mixed by the Corporation, excluding routine expenditures, the value of which in the aggregate exceeds five percent (5%) of the total assets of the Corporation; e) Selling, exchanging, or otherwise disposing of all or substantially all of the Corporation's assets; f) Any incurrence or guarantee of indebtedness by the Corporation that in the aggregate exceeds five percent (5%) of the total assets of the Corporation; g) Any merger, acquisition, or consolidation of the Corporation or entering into any joint business venture with any other person, corporation or other legal entity that exceeds five percent (5%) of the total assets of the Corporation; h) Any dissolution of the Corporation; i) Any proposed amendments to the affiliation agreement between the Corporation and The UTSW Medical School (Medical School); (j) Appointment and removal of directors in accordance with Article 3 of these Bylaws; (k) Creation, acquisition, or disposition of any subsidiary or affiliated entity of the Corporation; the value of which in the aggregate exceeds five percent (5%) of the total assets of the Corporation; and (l) Approval of the annual budget for the Corporation. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is presented to the organization's Audit Committee. The Chief Financial Officer provides a detailed review of the Form 990 and answers questions presented by the Committee members. Form 990, Part VI, Section B, line 12c The Board members receive a copy of the policy, along with a Disclosure of possible Conflict of Interests form to complete, with their annual Board appointment letter. All disclosures made are reviewed by the Chief Compliance Officer and Vice President of Legal Affairs and Governance prior to being presented and discussed at a meeting of the Board of Directors to determine if further action is required. Form 990, Part VI, Section B, line 15 The corporation's CEO, President, other officers, and key employees are employed and compensated by Children's Medical Center of Dallas ("Children's"). The Children's process is as follows: 1. The Human Resources Committee of the Board is responsible for setting the compensation for executives, except the President and CEO which is set by the Board of Directors. The Committee is comprised of independent, non-employee directors with no conflict of interest regarding executive compensation. A written compensation philosophy has been developed by the Human Resources Committee for timeliness and appropriateness. The philosophy defined desired comparator groups for compensation surveys. The comparator groups are from domestic healthcare industry sectors only and do not include any non-healthcare organizations. 2. The compensation philosophy also defines target levels relative to the marketplace comparator groups for base pay, base pay plus incentive pay, and fringe benefits provided to Children's executives. A third-party consultant, Sullivan Cotter, is engaged by the Human Resources Committee and provides independent, expert consulting services in the area of executive compensation market surveying, pay and benefits program design, and administrative services. Salaries for Children's executives (except for the President and CEO) are set by comparing the salaries paid for comparable positions in integrated systems academic medical centers and children's hospitals in similar size and scope of services to Children's. 3. The salary for the President and CEO is set in reference to salaries paid for Presidents and CEOs of children's hospitals in similar size and scope of services to Children's. The data is compiled by Sullivan Cotter and they develop and update annually salary ranges unique to each executive position. The Human Resources Committee approves base pay for each executive (except the President and CEO, whose base pay is approved by the Board of Directors) aimed in the aggregate at approximately the middle of executive pay ranges. 4. For other officers and key employees, Children's uses a combination of job evaluation and survey data to determine the market pay range. Form 990, Part VI, Section C, line 19 Governing documents, conflict of interest policy and financial statements are made available upon request. Form 990, Part VII, Section A - Average Hours per Week Average hours per week have been identified as 60 hours/week for the CEO as there are numerous offsite community events which involve weekend, breakfast, and evening meetings. Average hours per week for Executive Vice Presidents and Senior Vice Presidents have been identified as 55 hours per week as they are involved with limited offsite community events. Average hours per week for Vice Presidents have been identified as 50 hours per week as they have some involvement with offsite community events. Key Employees and Highest Compensated Employees have been identified as 40 hours per week. Other Fees Form 990, Part IX, line 11g Contract Medical: Program service expenses 104,064,814. Management and general expenses 12,102,943. Fundraising expenses 0. Total expenses 116,167,757. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Acc Pens Liab-OCI 3,909,336. Net Assets-CMCF-Unrest&Temp Rest 7,477,497. Net Assets-CMCF-Endowment 23,081,581. Children's Medical Center Foundation 1935 Medical District Drive Dallas TX 75235 752062015 Foundation TX 501(c)(3) Line 7 Children's Hlth Svc of TX 0 Anesthesiologists For Children 1935 Medical District Drive Dallas TX 75235 752917570 Physicians TX 501(c)(3) Line 9 Children's Medical Center of Dallas 1 Dallas Phys Medical Svcs for Children Inc 1935 Medical District Drive Dallas TX 75235 810584868 Physicians TX 501(c)(3) Line 9 Children's Medical Center of Dallas 1 Children's Health Svc of Texas 1935 Medical District Drive Dallas TX 75235 752062019 Management Company TX 501(c)(3) Line 11a, I N/A 0 Physicians For Children 1935 Medical District Drive Dallas TX 75235 752854505 Physicians TX 501(c)(3) Line 9 Children's Medical Center of Dallas 1 Children's Med Ctr Research Inst at UTSWMC 1935 Medical District Drive Dallas TX 75235 433462044 Research Institute TX Pending Pending Children's Hlth Svc of TX 0 Complex Care Medical Services 1935 Medical District Drive Dallas TX 75235 461893597 Medical Services TX Pending Pending Children's Medical Center of Dallas 1 Pediatric Partners For Children 1935 Medical District Drive Dallas TX 75235 461917702 Clinically Integrated Network TX Pending Pending Children's Medical Center of Dallas 1 Children's Medical Center Services 1935 Medical District Drive Dallas TX 75235 461934007 Medical Services TX Pending Pending Children's Medical Center of Dallas 1 Southwestern Medical District 1935 Medical District Drive Dallas TX 75235 204101612 Medical District TX 501(c)(3) Line 11a, I N/A 0 Women's Auxiliary of CMCD 1935 Medical District Drive Dallas TX 75235 752485538 Women's Auxiliary TX 501(c)(3) Line 9 N/A 0 Alternative Care Systems 1935 Medical District Drive Dallas TX 75235 752244475 Other Medical Svcs TX Children's Hlth Svc of TX C 0 Children's Insurance Co 76 St Paul Street Suite 500 Burlington VT 05401 030328102 Insurance VT Children's Med Ctr of Dallas C 270070 1.00000 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 Anesthesiologists for Children D 5978178 actual cost Anesthesiologists for Children Q 648538 actual cost Physicians for Children D 20295515 actual cost Physicians for Children Q 775110 actual cost Dallas Phys Medical Svcs for Children Inc D 127481 actual cost Dallas Phys Medical Svcs for Children Inc Q 65144 actual cost