TY 2012 Form 990 Schedule O

efile Public Visual Render ObjectId: 201401199349300305 - Submission: 2014-04-29 TIN: 39-0938661

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

BURNETT MEDICAL CENTER INC

Employer identification number

39-0938661

Identifier	Return Reference	Explanation
	FORM 990, PART VI, SECTION A, LINE 6	EACH PERSON, BUSINESS, CORPORATION OR ORGANIZATION WHO HAS CONTRIBUTED AND PAID ONE HUNDRED DOLLARS OR MORE TO BURNETT MEDICAL CENTER, INC. "THE CORPORATION" SHALL BE A LIFETIME MEMBER OF THE CORPORATION. EACH PERSON, BUSINESS, CORPORATION, OR ORGANIZATION IS ENTITLED TO HOLD A MAXIMUM OF ONE MEMBERSHIP CERTIFICATE. A HUSBAND AND WIFE, OR TWO OR MORE RELATED PERSONS, MAY HOLD A MEMBERSHIP AS JOINT TENANTS, HOWEVER, ONLY ONE VOTE PER MEMBERSHIP SHALL BE PERMITTED.
	FORM 990, PART VI, SECTION A, LINE 7A	THE DUTIES OF THE MEMBERS OF THE CORPORATION SHALL BE: THE FORMULATION AND DEVELOPMENT OF THE OVERALL PURPOSES; OBJECTIVES AND PHILOSOPHY OF THE CORPORATION; THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS; THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE CORPORATION OR ITS MERGER WITH ANOTHER CORPORATION.
	FORM 990, PART VI, SECTION B, LINE 11	THE BOARD OF DIRECTORS FOR BURNETT MEDICAL CENTER, INC. REVIEWS AND APPROVES THE FORM 990 PRIOR TO SUBMISSION.
	FORM 990, PART VI, SECTION B, LINE 12C	BURNETT MEDICAL CENTER, INC. HAS A CONFLICT OF INTEREST POLICY. THE PURPOSE OF THIS POLICY IS TO PROTECT THE INTEREST OF BURNETT MEDICAL CENTER WHEN IT IS CONTEMPLATING ENTERING INTO A TRANSACTION OR ARRANGEMENT THAT MIGHT BENEFIT THE PRIVATE INTEREST OF AN OFFICER OR DIRECTOR OF THE CORPORATION. IT IS EXPECTED THAT SUCH PERSONS SHALL EXERCISE THE UTMOST GOOD FAITH IN ALL TRANSACTIONS TOUCHING UPON THEIR DUTIES AT BURNETT MEDICAL CENTER AND ITS PROPERTY. ALL MEMBERS OF THE BOARD COMPLETE A DISCLOSURE FORM UPON APPOINTMENT, AND REVIEW AND SIGN IT ANNUALLY THEREAFTER. THIS STATEMENT ESTABLISHES THE DUTY OF AN INTERESTED PARTY TO DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST DISCLOSE ALL MATERIAL FACTS. AFTER ANY SUCH DISCLOSURE, HE/SHE SHALL LEAVE THE GOVERNING BOARD MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD MEMBERS. IF THE BOARD HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS OF SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF MEMBERS FAIL TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION.
	FORM 990, PART VI, SECTION B, LINE 15	BURNETT MEDICAL CENTER INC.'S EXECUTIVE COMPENSATION POLICY IS DESIGNED WITH THE GOAL OF PROVIDING REMUNERATION THAT IS FAIR, REASONABLE AND COMPETITIVE. THE HOSPITAL BOARD MAY ESTABLISH A COMPENSATION COMMITTEE OR MAY ACT AS A COMMITTEE OF THE WHOLE IN EXECUTIVE SESSION. THE COMMITTEE OVERSEES THE TOTAL COMPENSATION PACKAGES TO ENSURE THAT THEY ARE COMPETITIVE WITH OTHER HEALTHCARE ORGANIZATIONS, REFLECT JOB RESPONSIBILITIES AND REQUIREMENTS AND ARE FAIR, EQUITABLE, AND CONSISTENTLY MANAGED. THE COMMITTEE MEETS AS OFTEN AS IT DEEMS APPROPRIATE TO CARRY OUT ITS RESPONSIBILITIES. IN GENERAL, BURNETT MEDICAL CENTER POSITIONS TOTAL EXECUTIVE COMPENSATION AT THE MEDIAN OF THE MARKET. THE BOARD OF DIRECTORS USES CONTEMPORANEOUS DATA INCLUDING EXECUTIVE COMPENSATION DATA FROM THE WISCONSIN HOSPITAL ASSOCIATION AS A GUIDE WHEN APPROVING THE COMPENSATION OF THE ADMINISTRATOR AND CHIEF FINANCIAL OFFICER. THE POLICY IS MEANT TO BE FLEXIBLE SO THAT COMPENSATION CAN BE ABOVE OR BELOW THE MEDIAN BASED ON EXPERIENCE, PERFORMANCE, SIZE AND COMPLEXITY OF ORGANIZATION, AND BUSINESS NEED TO ATTRACT AND RETAIN EXECUTIVE TALENT.
	FORM 990, PART VI, SECTION C, LINE 19	BURNETT MEDICAL CENTER, INC. MAKES IT FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS.
OTHER FEES	FORM 990, PART IX, LINE 11G	LAB PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 137,092. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 137,092. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 195,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 195,838. DIETARY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 397,143. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 397,143. ER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 141,220. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 141,220. LAUNDRY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 180,780. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 180,780. CONTRACTED PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 399,050. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 399,050. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 887,310. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 887,310. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 134,500. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 134,500.
CHANGES IN NET ASSETS OR FUND BALANCES:	FORM 990, PART XI, LINE 9:	CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: -59,475.
OVERSIGHT OF THE AUDIT	FORM 990, PART XII, LINE 2C	BURNETT MEDICAL CENTER, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.

Identifier

Return Reference

Explanation

FORM 990, PART VI, SECTION A, LINE 6

EACH PERSON, BUSINESS, CORPORATION OR ORGANIZATION WHO HAS CONTRIBUTED AND PAID ONE HUNDRED DOLLARS OR MORE TO BURNETT MEDICAL CENTER, INC. "THE CORPORATION" SHALL BE A LIFETIME MEMBER OF THE CORPORATION. EACH PERSON, BUSINESS, CORPORATION, OR ORGANIZATION IS ENTITLED TO HOLD A MAXIMUM OF ONE MEMBERSHIP CERTIFICATE. A HUSBAND AND WIFE, OR TWO OR MORE RELATED PERSONS, MAY HOLD A MEMBERSHIP AS JOINT TENANTS, HOWEVER, ONLY ONE VOTE PER MEMBERSHIP SHALL BE PERMITTED.

FORM 990, PART VI, SECTION A, LINE 7A

THE DUTIES OF THE MEMBERS OF THE CORPORATION SHALL BE: THE FORMULATION AND DEVELOPMENT OF THE OVERALL PURPOSES; OBJECTIVES AND PHILOSOPHY OF THE CORPORATION; THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS; THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE CORPORATION OR ITS MERGER WITH ANOTHER CORPORATION.

FORM 990, PART VI, SECTION B, LINE 11

THE BOARD OF DIRECTORS FOR BURNETT MEDICAL CENTER, INC. REVIEWS AND APPROVES THE FORM 990 PRIOR TO SUBMISSION.

FORM 990, PART VI, SECTION B, LINE 12C

BURNETT MEDICAL CENTER, INC. HAS A CONFLICT OF INTEREST POLICY. THE PURPOSE OF THIS POLICY IS TO PROTECT THE INTEREST OF BURNETT MEDICAL CENTER WHEN IT IS CONTEMPLATING ENTERING INTO A TRANSACTION OR ARRANGEMENT THAT MIGHT BENEFIT THE PRIVATE INTEREST OF AN OFFICER OR DIRECTOR OF THE CORPORATION. IT IS EXPECTED THAT SUCH PERSONS SHALL EXERCISE THE UTMOST GOOD FAITH IN ALL TRANSACTIONS TOUCHING UPON THEIR DUTIES AT BURNETT MEDICAL CENTER AND ITS PROPERTY. ALL MEMBERS OF THE BOARD COMPLETE A DISCLOSURE FORM UPON APPOINTMENT, AND REVIEW AND SIGN IT ANNUALLY THEREAFTER. THIS STATEMENT ESTABLISHES THE DUTY OF AN INTERESTED PARTY TO DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST DISCLOSE ALL MATERIAL FACTS. AFTER ANY SUCH DISCLOSURE, HE/SHE SHALL LEAVE THE GOVERNING BOARD MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD MEMBERS. IF THE BOARD HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS OF SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF MEMBERS FAIL TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION.

FORM 990, PART VI, SECTION B, LINE 15

BURNETT MEDICAL CENTER INC.'S EXECUTIVE COMPENSATION POLICY IS DESIGNED WITH THE GOAL OF PROVIDING REMUNERATION THAT IS FAIR, REASONABLE AND COMPETITIVE. THE HOSPITAL BOARD MAY ESTABLISH A COMPENSATION COMMITTEE OR MAY ACT AS A COMMITTEE OF THE WHOLE IN EXECUTIVE SESSION. THE COMMITTEE OVERSEES THE TOTAL COMPENSATION PACKAGES TO ENSURE THAT THEY ARE COMPETITIVE WITH OTHER HEALTHCARE ORGANIZATIONS, REFLECT JOB RESPONSIBILITIES AND REQUIREMENTS AND ARE FAIR, EQUITABLE, AND CONSISTENTLY MANAGED. THE COMMITTEE MEETS AS OFTEN AS IT DEEMS APPROPRIATE TO CARRY OUT ITS RESPONSIBILITIES. IN GENERAL, BURNETT MEDICAL CENTER POSITIONS TOTAL EXECUTIVE COMPENSATION AT THE MEDIAN OF THE MARKET. THE BOARD OF DIRECTORS USES CONTEMPORANEOUS DATA INCLUDING EXECUTIVE COMPENSATION DATA FROM THE WISCONSIN HOSPITAL ASSOCIATION AS A GUIDE WHEN APPROVING THE COMPENSATION OF THE ADMINISTRATOR AND CHIEF FINANCIAL OFFICER. THE POLICY IS MEANT TO BE FLEXIBLE SO THAT COMPENSATION CAN BE ABOVE OR BELOW THE MEDIAN BASED ON EXPERIENCE, PERFORMANCE, SIZE AND COMPLEXITY OF ORGANIZATION, AND BUSINESS NEED TO ATTRACT AND RETAIN EXECUTIVE TALENT.

FORM 990, PART VI, SECTION C, LINE 19

BURNETT MEDICAL CENTER, INC. MAKES IT FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS.

OTHER FEES

FORM 990, PART IX, LINE 11G

LAB PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 137,092. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 137,092. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 195,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 195,838. DIETARY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 397,143. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 397,143. ER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 141,220. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 141,220. LAUNDRY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 180,780. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 180,780. CONTRACTED PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 399,050. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 399,050. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 887,310. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 887,310. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 134,500. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 134,500.

CHANGES IN NET ASSETS OR FUND BALANCES:

FORM 990, PART XI, LINE 9:

CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: -59,475.

OVERSIGHT OF THE AUDIT

FORM 990, PART XII, LINE 2C

BURNETT MEDICAL CENTER, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

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