FORM 990, PAGE 2, PART III, LINE 4D |
CANTON-POTSDAM MEDICAL PRACTICE OPERATES OTHER OUTPATIENT CLINIC LOCATIONS INCLUDING THE FOLLOWING: OB SERVICES: LOCATED IN CANTON, NY AND GOUVERNEUR, NY, THESE CLINICS SERVED APPROXIMATELY 2539 PATIENTS IN 2015. OB SERVICES WERE DISCONTINUED AS PART OF THIS ORGANIZATION AS OF THE END OF 2015 AND BECAME PRACTICES UNDER RELATED ORGANIZATION, CANTON-POTSDAM HOSPITAL. ENT SERVICES: LOCATED IN POTSDAM, NY, THIS CLINIC OPENED IN NOVEMBER 2014 AND SERVED APPROXIMATELY 3,083 PATIENTS IN 2015. FAMILY PRACTICE: LOCATED IN COLTON, NY, THIS CLINIC SERVED APPROXIMATELY 2463 PATIENTS IN 2015. |
FORM 990, PAGE 6, PART VI, LINE 3 |
CANTON-POTSDAM MEDICAL PRACTICE DOES NOT HAVE ANY EMPLOYEES ON ITS PAYROLL. ALL "EMPLOYEES" , INCLUDING THOSE THAT PERFORM MANAGEMENT FUNCTIONS, ARE CONTRACTED THROUGH CANTON-POTSDAM HOSPITAL, RELATED TAX EXEMPT ORGANIZATION. EMPLOYEES OF CANTON-POTDAM HOSPITAL ARE LEASED TO CANTON- POTSDAM MEDICAL PRACTICE TO PROVIDE ALL MEDICAL STAFF AND MANAGEMENT SERVICES. SERVICE AGREEMENTS ARE IN PLACE BETWEEN THE TWO RELATED ORGANIZATIONS. CANTON-POTSDAM HOSPITAL INVOICES CANTON-POTSDAM MEDICAL PRACTICE FOR THESE SERVICES. KEY EMPLOYEE, RICHARD JACOBS, IS AN EMPLOYEE OF CANTON-POTSDAM HOSPITAL WHO IS RESPONSIBLE FOR THE FINANCIAL REPORTING OF CANTON-POTSDAM MEDICAL PRACTICE. ROBERT T. ROGERS, II, MD, IS AN EMPLOYEE OF CANTON-POTSDAM HOSPITAL WHO IS THE SOLE MEMBER MANAGER OF THE PLLC. |
FORM 990, PAGE 6, PART VI, LINE 8B |
CANTON-POTSDAM MEDICAL PRACTICE DID NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY, AND THUS NO COMMITTEE MEETINGS WERE HELD. |
FORM 990, PAGE 6, PART VI, LINE 11B |
THE FORM 990 IS PREPARED BY CANTON-POTSDAM HOSPITAL'S FINANCE DEPARTMENT STAFF MEMBERS. UPON COMPLETION, A COPY WITH SUPPORTING DOCUMENTATION IS REVIEWED BY THE VICE PRESIDENT FOR FINANCE AND THE CONTROLLER. FURTHERMORE, THE FORM WAS PROVIDED TO THE CANTON-POTSDAM MEDICAL PRACTICE ADVISORY COMMITTEE FOR FURTHER REVIEW AND COMMENT. AFTER REVIEW, ANY CHANGES ARE MADE AND A COPY IS PRESENTED TO THE SOLE MEMBER OF CANTON-POTSDAM MEDICAL PRACTICE, ROBERT T. ROGERS, II, MD FOR HIS REVIEW AND APPROVAL. |
FORM 990, PAGE 6, PART VI, LINE 12C |
THE KEY EMPLOYEE AND SOLE MEMBER OF CANTON-POTSDAM MEDICAL PRACTICE ARE EMPLOYEES OF CANTON-POTSDAM HOSPITAL, RELATED ORGANIZATION. ALL EMPLOYEES ADHERE TO CANTON-POTSDAM HOSPITAL'S WRITTEN CONFLICT OF INTEREST POLICY. DISCLOSURE STATEMENTS ARE REVIEWED ANNUALLY. |
FORM 990, PAGE 6, PART VI, LINE 15A |
LINE 15A: AS STATED ABOVE IN THIS SCHEDULE O, CANTON-POTSDAM MEDICAL PRACTICE DOES NOT HAVE ANY EMPLOYEES ON ITS PAYROLL AND ALL "EMPLOYEES" ARE CONTRACTED THROUGH CANTON-POTSDAM HOSPITAL, RELATED TAX EXEMPT ORGANIZATION. AS SUCH, THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF CANTON-POTSDAM HOSPITAL SEEKS THE INPUT OF A CONSULTING FIRM WITH NATIONAL EXPERIENCE TO REVIEW THE COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AND THE REGULATORY COMPLIANCE ISSUES OF NOT-FOR-PROFITS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE A RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIALS COMPENSATION PACKAGE. |
FORM 990, PAGE 6, PART VI, LINE 15B |
THE KEY EMPLOYEE AND SOLE MEMBER OF CANTON-POTSDAM MEDICAL PRACTICE ARE EMPLOYEES OF CANTON-POTSDAM HOSPITAL, RELATED ORGANIZATION. COMPENSATION OF EMPLOYEES IS DETERMINED BY CANTON-POTSDAM HOSPITAL'S PROCESSES FOR DETERMINING COMPENSATION. THEY ARE AS FOLLOWS: THE COMPENSATION OF OTHER KEY EMPLOYEES IS DETERMINED PRIMARILY BY THE WORK OF THE HUMAN RESOURCE DEPARTMENT, THE RECOMMENDATION OF THE VICE PRESIDENT OF HUMAN RESOURCES (HR), AND BY INFORMATION GATHERED FROM INDEPENDENT SURVEY DATA OF NATIONAL AND SURROUNDING MARKETS. THE VICE PRESIDENT OF HUMAN RESOURCES WILL REVIEW THE SURVEY DATA TO ESTIMATE SALARY RANGES AND COMPENSATION PACKAGES. THE VP OF HR MAKES THE RECOMMENDATION TO THE CEO. THE CEO WILL BRING THE INFORMATION TO THE COMPENSATION COMMITTEE. AFTER DELIBERATIONS AND CONSIDERATIONS, THE COMPENSATION COMMITTEE WITH THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL. |
FORM 990, PAGE 6, PART VI, LINE 19 |
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
FORM 990, PART XI, LINE 9 |
TRANSFER FROM AFFILIATE (CANTON-POTSDAM HOSPITAL) 1,650,435 CONTRIBUTIONS FOR CAPITAL ACQUISITIONS 1,302 TOTAL 1,651,737 |