2013-11-14T16:55:18-06:00 2012-12-31 910189318 MOSS ADAMS LLP 101 SECOND STREET 9TH FLOOR SAN FRANCISCO CA 94105 990 2012-01-01 956419205 SANSUM CLINIC SANS 8056817700 PO BOX 1200 SANTA BARBARA CA 931021200 CHAD HINE 8056817700 2013-11-11 1 RENIE BURBANK P00159653 4159561500 2012 2016-02-25 16:41:14Z CHAD HINE PO BOX 1200 SANTA BARBARA CA 931021200 198814376 0 X WWW.SANSUMCLINIC.ORG X 1921 CA TO PROVIDE MEDICAL SERVICES TO THE GENERAL PUBLIC. 23 22 1163 30 0 0 2169704 2646624 173022902 190880211 221475 154672 1701966 4734232 177116047 198415739 0 0 0 0 50887227 57192434 0 0 329098 122865722 136372109 173752949 193564543 3363098 4851196 86024320 93339149 56461831 58427925 29562489 34911224 X THE CLINIC PROVIDES MEDICAL SERVICES TO THE GENERAL PUBLIC, INCLUDING CHARITY CARE TO PATIENTS WHO ARE UNABLE TO PAY AND THOSE UNDER MEDICARE AND MEDI-CAL PROGRAMS AT LESS THAN STANDARD CHARGES. OTHER HEALTH SERVICES IN THE COMMUNITY ARE ALSO PROVIDED, SUCH AS WELLNESS PROGRAMS, EDUCATIONAL SERVICE, SPEAKING ENGAGEMENTS AND INTERNSHIP PROGRAMS. 0 0 159071519 190880211 SEE SCHEDULE O 159071519 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 435 0 1 1163 1 0 0 0 0 0 0 0 0 0 0 X 23 22 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CA X CHAD HINE 8056817700 PO BOX 1200 SANTA BARBARA CA 931021200 VICKI HAZARD 1.00 X X 0 0 0 ED ROSENBLATT 1.00 X X 0 0 0 LARS BRUUN-ANDERSEN 1.00 X 0 0 0 KEN COATES 1.00 X 0 0 0 CHRIS CORPUZ 1.00 X 0 0 0 CHARLIE COX 1.00 X 0 0 0 ROGER CRATON 1.00 X 0 0 0 JANET GARUFIS 1.00 X 0 0 0 PAUL HARTLOFF JR 1.00 X 0 0 0 ROGER HORTON 1.00 X 0 0 0 CHUCK KAYE 1.00 X 0 0 0 RON LATIMER MD 1.00 X 0 0 0 VICKY MACGREGOR 1.00 X 0 0 0 JULIE MCGOVERN 1.00 X 0 0 0 JAMES MCNAMARA MD 1.00 X 0 0 0 STEVE MCHUGH 1.00 X 0 0 0 ART MEROVICK 1.00 X 0 0 0 DAVID RAPHAEL MD 1.00 X 0 0 0 GEORGE RUSZNAK 1.00 X 0 0 0 MIKE STEIN 1.00 X 0 0 0 JOE TUMBLER 1.00 X 0 0 0 BETH VOS 1.00 X 0 0 0 MICHAEL BERNSTEIN MD 1.00 X 13200 0 0 KURT RANSOHOFF MD 40.00 X 280324 0 0 VINCE JENSEN 40.00 X 263154 0 1846 CHAD HINE 40.00 X 295769 0 21052 CHRISTINE MCNAMARA 40.00 X 156461 0 36900 JENNIFER THOMAS 40.00 X 196757 0 34142 TOM COLBERT 40.00 X 158535 0 5521 MARJORIE NEWMAN 40.00 X 146758 0 17000 SEAN JOHNSON 40.00 X 224340 0 36892 LOUIS GIAMBELUCA 40.00 X 157929 0 3532 1893227 0 156885 42 0 1 0 SANSUM SANTA BARBARA MEDICAL CLINIC INC PO BOX 1200 SANTA BARBARA CA 93102 PROFESSIONAL SERVICES 58099000 PACIFIC DIAGNOSTIC LABORATORIES PO BOX 8180 GOLETA CA 93118 LABORATORY SERVICES 3899962 JACKSON MEDICAL GROUP 517 WEST JUNIPERO SANTA BARBARA CA 93105 PROFESSIONAL SERVICES 3663990 SANTA BARBARA RADIOLOGY MEDICAL GROUP 320 W PUEBLO SANTA BARBARA CA 93101 RADIOLOGY SERVICES 2979036 ANESTHESIA MEDICAL GROUP 514 W PUEBLO SANTA BARBARA CA 93105 PROFESSIONAL SERVICES 1702457 111 2646624 369189 2646624 MEDICAL SRVC REVENUE 621110 190880211 190880211 190880211 154672 154672 616358 398637 217721 217721 217721 MISCELLANEOUS 624100 4469348 4469348 INCOME FROM K-1S 900099 47163 47163 4516511 198415739 190880211 0 4888904 X 1068706 1068706 42967249 34852541 7930894 183814 1016775 749985 266790 9002092 7088814 1876557 36721 3137612 2478019 646102 13491 263178 207852 55326 150000 118467 31533 82428619 65100355 17270338 57926 703843 555880 147063 900 4557596 3599488 921862 36246 2289489 1808189 481300 5547227 4381081 1166146 83418 65882 17536 184219 145492 38727 1496937 1182249 314688 5321001 4202412 1118589 1460932 1153813 307119 MEDICAL SUPPLIES 18282671 18282671 PHARMACEUTICAL SUPPLIES 9430817 9430817 REPAIRS/MAINTENANCE 2400520 1895879 504641 PROV. FOR UNCOLLECTIBLE 1771600 1771600 42 33 9 193564543 159071519 34163926 329098 8210280 11439704 12109844 7493441 9346085 14606930 2817077 3295173 1676876 1917526 1242836 1703754 104256078 65562888 37399755 38693190 2880357 3379471 432130 435806 9909080 10374154 86024320 93339149 19154118 23420848 24785745 23659060 6489814 4467762 6032154 6880255 56461831 58427925 X 25818949 29916362 2944304 4179646 799236 815216 29562489 34911224 86024320 93339149 X 4851196 544702 -47163 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3191729 23957 287194 3502880 3256051 13799 -78121 3191729 2933851 33680 288520 3256051 2292447 255486 385918 2933851 1952796 839584 -499933 2292447 0.84000 0.16000 0 0 6033858 6033858 33888998 19392785 14496213 61333984 46170103 15163881 2999238 2999238 38693190 BOND CONSTRUCTION AND RESERVE FUNDS 3908881 BOND ISSUANCE COSTS, NET OF AMORTIZATION 1084680 DEFERRED COMPENSATION PLAN ASSETS 2686255 OTHER ASSETS 466338 INSURANCE RECEIVABLE 2228000 10374154 DEFERRED COMPENSATION PLAN LIABILITIES 2686255 MEDICAL MALPRACTICE LIABILITY 4194000 6880255 X 196923957 544702 -1771600 -1226898 198150855 264884 264884 198415739 191575222 0 191575222 1989321 1989321 193564543 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF ENDOWMENT FUNDS ARE RELATED TO THE PURPOSE FOR WHICH THEY WERE GIVEN. THERE ARE RESTRICTED FUNDS SET UP FOR DIGITAL MAMMOGRAPHY, CYSTIC FIBROSIS, PHYSICIAN HOUSING, TECHNOLOGY IMPROVEMENTS, AND COLONOSCOPIES FOR NEIGHBORHOOD CLINIC PATIENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE CLINIC RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THERE WERE NO UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2012 OR 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE RECLASSED TO EXPENSE SECTION -1,771,600. PART XI, LINE 4B - OTHER ADJUSTMENTS: GROSS RENTAL INCOME RECLASSED FROM EXPENSE SECTION 616,358. BOOK/TAX DIFFERENCE IN PARTNERSHIP INCOME 47,163. RENTAL EXPENSES NETTED WITH RENTAL INCOME -398,637. PART XII, LINE 4B - OTHER ADJUSTMENTS: GROSS RENTAL INCOME RECLASSIFIED TO REVENUES 616,358. RENTAL EXPENSES RECLASSIFIED TO REVENUES -398,637. BAD DEBT EXPENSE RECLASSED FROM REVENUE SECTION 1,771,600. X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KURT RANSOHOFF MD 280324 0 0 0 0 0 0 0 0 0 280324 0 0 0 VINCE JENSEN 263154 0 0 0 0 0 0 0 1846 0 265000 0 0 0 CHAD HINE 295769 0 0 0 0 0 17000 0 4052 0 316821 0 0 0 CHRISTINE MCNAMARA 156461 0 0 0 0 0 32900 0 4000 0 193361 0 0 0 JENNIFER THOMAS 196757 0 0 0 0 0 30000 0 4142 0 230899 0 0 0 TOM COLBERT 158535 0 0 0 0 0 3161 0 2360 0 164056 0 0 0 MARJORIE NEWMAN 146758 0 0 0 0 0 17000 0 0 0 163758 0 0 0 SEAN JOHNSON 224340 0 0 0 0 0 17000 0 19892 0 261232 0 0 0 LOUIS GIAMBELUCA 157929 0 0 0 0 0 0 0 3532 0 161461 0 0 0 PART I, LINE 1A PAYMENT FOR MONTHLY DUES FOR MEMBERSHIP AT THE LA CUMBRE COUNTRY CLUB WAS PAID ON BEHALF OF KURT RANSOHOFF. THE AMOUNT WAS INCLUDED IN HIS FORM W-2. X 5 369189 FAIR MARKET VALUE 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 CHRISTINE MCNAMARA, VICE PRESIDENT OF PROFESSIONAL SERVICES, AND DR. JAMES MCNAMARA, MEMBER OF THE BOARD OF TRUSTEES, HAVE A FAMILY RELATIONSHIP. ALSO, MICHAEL STEIN, MEMBER OF THE BOARD OF TRUSTEES, HAS A FAMILY MEMBER EMPLOYED AT SANSUM CLINIC. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEES HAS DELEGATED THE FIDUCIARY RESPONSIBILITY OF THE REVIEW AND APPROVAL PROCESS OF THE 990 TAX RETURN TO THE FINANCE COMMITTEE AND THE CHIEF FINANCIAL OFFICER; UPON APPROVAL BY THE FINANCE COMMITTEE THE 990 TAX RETURN GOES TO THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THE FORM 990 WAS PROVIDED TO ALL MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS ELECTRONICALLY PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. ONCE FINAL APPROVAL IS GIVEN, THE 990 TAX RETURN IS SUBMITTED TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE POLICY OF SANSUM CLINIC TO MAIL OUT, ON AN ANNUAL BASIS, A CONFLICT OF INTEREST STATEMENT TO THE BOARD OF TRUSTEES FOR COMPLETION. THE CONFLICT OF INTEREST STATEMENTS ARE REVIEWED AND ALL RESPONSES ARE FILED. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS EXECUTIVE COMPENSATION PERIODICALLY. NO CHANGES TO EXECUTIVE COMPENSATION ARE IMPLEMENTED THAT ARE NOT BUDGETED FOR AND THAT ARE NOT CONSISTENT WITH THE AVERAGE RATE OF PAY INCREASES FOR OTHER COMPANY EMPLOYEES. ANY EXCEPTIONS TO THIS ARE APPROVED, IN ADVANCE, BY THE EXECUTIVE COMMITTEE PRIOR TO IMPLEMENTATION. FORM 990, PART VI, SECTION C, LINE 19 IT IS THE POLICY OF SANSUM CLINIC TO PROVIDE DOCUMENTATION UPON WRITTEN REQUEST BY MAIL TO THE CORPORATE LOCATION. OTHER FEES FORM 990, PART IX, LINE 11G OTHER NON-EMPLOYEE SERVICES: PROGRAM SERVICE EXPENSES 65,100,355. MANAGEMENT AND GENERAL EXPENSES 17,270,338. FUNDRAISING EXPENSES 57,926. TOTAL EXPENSES 82,428,619. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: BOOK/TAX DIFFERENCE IN PARTNERSHIP INCOME -47,163. AUDIT COMMITTEE AND OVERSIGHT 990, PART XII, LINE 2C THE BOARD OF TRUSTEES HAS DELEGATED FIDUCIARY RESPONSIBILITY OF THE OVERSIGHT OF THE AUDIT TO THE AUDIT COMMITTEE. THERE HAVE BEEN NO CHANGES TO THIS PROCESS FROM PRIOR YEAR. EXEMPT PURPOSE ACHIEVEMENTS FORM 990, PART III, LINE 4A IN FURTHERANCE OF ITS CHARITABLE PURPOSE, THE CLINIC PROVIDES MEDICAL CARE WITHOUT CHARGE OR AT REDUCED CHARGE TO RESIDENTS OF THE COMMUNITY, PRIMARILY THROUGH: (A) SERVICES PROVIDED AT NO CHARGE TO THE UNINSURED; (B) THE DIFFERENCE BETWEEN PUBLIC PROGRAM PAYMENTS (PRIMARILY MEDI-CAL) AND THE RELATED COSTS OF PROVIDING SUCH SERVICES; AND (C) THE SERVICES PROVIDED TO PATIENTS EXPRESSING A WILLINGNESS TO PAY BUT WHO ARE UNABLE DUE TO SOCIO-ECONOMIC FACTORS. ADDITIONAL ACTIVITIES UNDERTAKEN TO BENEFIT THE COMMUNITY AND TO FULFILL ITS MISSION OF PROVIDING HIGH QUALITY HEALTHCARE TO EVERY PATIENT IN AN ENVIRONMENT THAT FOSTERS CARING AND COMPASSION AND PROMOTES EDUCATION AND RESEARCH INCLUDE THE FOLLOWING: - PROVIDING FREE SPORTS PHYSICALS TO YOUTH WHO COULD NOT OTHERWISE AFFORD THEM. - PROVIDING THE LARGEST LOCAL FLU IMMUNIZATION CLINICS ANNUALLY FOR FREE OR FOR A NOMINAL DONATION. - PROVIDING FREE EYE EXAMINATIONS THROUGH SEE INTERNATIONAL TO CHILDREN WHO COULD NOT OTHERWISE AFFORD THEM. - PROVIDING MORE THAN 300 HEALTH EDUCATION CLASSES (E.G. ASTHMA, BACK AND NECK CARE, CHOLESTEROL, DIABETES, HEALTHY AGING, JOINT REPLACEMENT, STRESS, WEIGHT MANAGEMENT FOR CHILDREN AND ADULTS) THAT ARE OFFERED EACH YEAR. THE CLASSES ARE OPEN TO THE COMMUNITY, ARE OFFERED FOR FREE OR AT A NOMINAL FEE AND ARE AVAILABLE THROUGHOUT THE COUNTY. - LEADING CAMP WHEEZ AND PROVIDING PHYSICIANS AND SUPPORT STAFF FOR THIS WEEKLONG SUMMER CAMP FOR CHILDREN LIVING WITH ASTHMA. - COLLABORATING WITH SANTA BARBARA NEIGHBORHOOD CLINICS TO PROVIDE DIAGNOSTIC CARE AND SPECIALTY MEDICAL SERVICES TO RESIDENTS WHO COULD OTHERWISE NOT AFFORD THESE TESTS. - PROVIDING RELIABLE HEALTH AND RESOURCE INFORMATION FREE OF CHARGE TO ANY COMMUNITY MEMBER, PATIENTS AND NON-PATIENTS ALIKE, THROUGH OUR HEALTH RESOURCE CENTER. - PARTICIPATING IN A VARIETY OF RESEARCH PROJECT WITH PARTNERS SUCH AS UCLA, THE RAND CORPORATION AND SEVERAL PHARMACEUTICAL COMPANIES. - PARTICIPATING IN OVER A DOZEN ANNUAL HEALTH FAIRS AND FREE HEALTH SCREENING EVENTS. INVESTMENT IN OR PARTICIPATION IN A JOINT VENTURE OR SIMILAR ARRANGEMENT: 990, PART VI, LINE 16B SANSUM CLINIC HAS 3 AFFILIATION AGREEMENTS. DUE DILIGENCE WAS PERFORMED BY LEGAL COUNSEL AT THE TIME THE CLINIC ENTERED INTO THE AGREEMENTS. ONE AFFILIATION AGREEMENT IS WITH CANCER FOUNDATION OF SANTA BARBARA. THE AGREEMENT SPECIFIES THAT THE MEDICAL OPERATIONS OF THE CANCER CENTER WILL OPERATE IN ACCORDANCE WITH SANSUM CLINIC'S TAX EXEMPT PURPOSE. SANSUM CLINIC ALSO ENTERED INTO AFFILIATION AGREEMENTS WITH TWO MEDICAL GROUPS. THE PHYSICIANS OF BOTH MEDICAL GROUPS PROVIDE MEDICAL SERVICES AND TREATMENTS TO PATIENTS OF SANSUM CLINIC. THE PROVISION OF MEDICAL SERVICES ARE DETAILED OUT IN THE AGREEMENT ARE IN-LINE WITH THE ORGANIZATION'S EXEMPT PURPOSE. THE CLINIC ENGAGES LEGAL COUNSEL RELATING TO THE OPERATIONS AND SERVICES PROVIDED TO ENSURE PROCEDURES ARE FOLLOWED TO SAFEGUARD THEIR EXEMPT STATUS.