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ObjectId: 202331299349301133 - Submission: 2023-05-09
TIN: 22-2519596
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
21
Open to Public Inspection
Name of the organization
Dartmouth-Hitchcock Clinic
Employer identification number
22-2519596
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
.....
1b
Yes
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a?
....
2
Yes
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
.............
4a
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
....................
5a
No
b
Any related organization?
.......................
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
..................
6a
No
b
Any related organization?
......................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2021
Page 2
Schedule J (Form 990) 2021
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation in column (B) reported as deferred on prior Form 990
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
Joanne M Conroy MD
Trustee, Ex-Officio, CEO
(i)
(ii)
1,306,313
-------------
0
208,100
-------------
0
168,720
-------------
0
27,660
-------------
0
17,995
-------------
0
1,728,788
-------------
0
0
-------------
0
2
Jocelyn Chertoff MD
Trustee(Through 12/31/21)/VP Svc Ln & Dept Chair-Rad
(i)
(ii)
653,561
-------------
0
0
-------------
0
72,354
-------------
0
27,660
-------------
0
20,037
-------------
0
773,612
-------------
0
0
-------------
0
3
Sandra L Wong MD
Trustee (as of 3/25/22)/SVP Svc Ln & Dept Chair
(i)
(ii)
660,736
-------------
0
0
-------------
0
61,621
-------------
0
21,860
-------------
0
15,639
-------------
0
759,856
-------------
0
0
-------------
0
4
KURT K RHYNHART MD
TRUSTEE(Through 12/31/21)/Section Chief
(i)
(ii)
444,702
-------------
0
0
-------------
0
44,572
-------------
0
27,660
-------------
0
24,743
-------------
0
541,677
-------------
0
0
-------------
0
5
Carl W Dobson MD
Trustee/ Medical Director
(i)
(ii)
0
-------------
395,389
0
-------------
65,000
0
-------------
19,702
0
-------------
14,500
0
-------------
44,079
0
-------------
538,670
0
-------------
0
6
Gary L Freed MD
Trustee/ Physician
(i)
(ii)
678,773
-------------
0
100
-------------
0
63,652
-------------
0
21,860
-------------
0
3,118
-------------
0
767,503
-------------
0
0
-------------
0
7
Aaron J Mancuso MD
Trustee / Physician
(i)
(ii)
443,611
-------------
0
0
-------------
0
10,849
-------------
0
13,116
-------------
0
42,450
-------------
0
510,026
-------------
0
0
-------------
0
8
Nancy M Dunbar MD
Trustee (As of 1/1/22) / Physician
(i)
(ii)
352,687
-------------
0
0
-------------
0
31,587
-------------
0
21,860
-------------
0
44,907
-------------
0
451,041
-------------
0
0
-------------
0
9
Maria Padin MD
Chief Medical Officer, CGP
(i)
(ii)
468,432
-------------
0
0
-------------
0
53,578
-------------
0
27,660
-------------
0
36,467
-------------
0
586,137
-------------
0
0
-------------
0
10
Richard I Rothstein MD
Former Dept Chair/Srvc LN LDR - MED
(i)
(ii)
612,935
-------------
0
0
-------------
0
50,063
-------------
0
27,660
-------------
0
36,857
-------------
0
727,515
-------------
0
0
-------------
0
11
David Gladstone MD
CHF CLNCL PHYSCN - RADIOLOGY
(i)
(ii)
0
-------------
200,050
0
-------------
0
0
-------------
32,084
0
-------------
20,060
0
-------------
16,918
0
-------------
269,112
0
-------------
0
12
Wendy Fielding
Chief Financial Officer (as of 10/31/21)
(i)
(ii)
0
-------------
286,135
0
-------------
0
0
-------------
38,230
0
-------------
22,361
0
-------------
42,834
0
-------------
389,560
0
-------------
0
13
Aimee M Claiborne
Chief Human Resource Officer
(i)
(ii)
0
-------------
414,416
0
-------------
40,500
0
-------------
16,673
0
-------------
21,860
0
-------------
20,407
0
-------------
513,856
0
-------------
0
14
DANIEL P JANTZEN
Chief Financial Officer (through 10/31/21)
(i)
(ii)
0
-------------
799,582
0
-------------
85,000
0
-------------
136,757
0
-------------
27,660
0
-------------
35,530
0
-------------
1,084,529
0
-------------
0
15
Patrick F Jordan III MBA
Chief Operating Officer
(i)
(ii)
0
-------------
693,656
0
-------------
70,100
0
-------------
45,924
0
-------------
21,860
0
-------------
40,759
0
-------------
872,299
0
-------------
0
16
JOHN KACAVAS
Chief Legal Officer
(i)
(ii)
0
-------------
589,512
0
-------------
62,100
0
-------------
118,320
0
-------------
27,660
0
-------------
41,231
0
-------------
838,823
0
-------------
0
17
Stephen Leblanc
Chief Strategy Officer
(i)
(ii)
662,682
-------------
0
67,100
-------------
0
83,992
-------------
0
27,660
-------------
0
32,330
-------------
0
873,764
-------------
0
0
-------------
0
18
EDWARD MERRENS
Chief Clinical Officer
(i)
(ii)
659,793
-------------
0
67,000
-------------
0
69,566
-------------
0
27,660
-------------
0
20,587
-------------
0
844,606
-------------
0
0
-------------
0
19
Susan A Reeves EDDRN
Executive VP (medical center)
(i)
(ii)
0
-------------
595,393
0
-------------
60,250
0
-------------
82,940
0
-------------
27,660
0
-------------
41,293
0
-------------
807,536
0
-------------
0
20
Matthew Haag
Chief Development Officer
(i)
(ii)
0
-------------
382,093
0
-------------
38,625
0
-------------
23,959
0
-------------
0
0
-------------
18,061
0
-------------
462,738
0
-------------
0
21
GEORGE T BLIKE MD
Former/ Chief Quality & Value Officer
(i)
(ii)
222,135
-------------
0
0
-------------
0
22,900
-------------
0
20,819
-------------
0
0
-------------
0
265,854
-------------
0
0
-------------
0
22
Peter D Solberg MD
Chief Health Information Officer
(i)
(ii)
407,250
-------------
0
0
-------------
0
39,803
-------------
0
27,660
-------------
0
44,316
-------------
0
519,029
-------------
0
0
-------------
0
23
Karen Clements RNBSNMSB
Chief Nursing Officer
(i)
(ii)
0
-------------
347,266
0
-------------
350
0
-------------
30,153
0
-------------
21,860
0
-------------
15,392
0
-------------
415,021
0
-------------
0
24
Staci Hermann PHARMDMS
CHIEF PHARMACY OFFICER
(i)
(ii)
0
-------------
273,428
0
-------------
0
0
-------------
26,468
0
-------------
13,116
0
-------------
17,609
0
-------------
330,621
0
-------------
0
25
Simon Hillier
Dept Chair ANESTHESIOLOGY
(i)
(ii)
551,555
-------------
0
0
-------------
0
59,178
-------------
0
27,660
-------------
0
37,136
-------------
0
675,529
-------------
0
0
-------------
0
26
Jeffrey Obrien MHA
Chief Operating Officer - DHMC
(i)
(ii)
0
-------------
343,830
0
-------------
0
0
-------------
41,775
0
-------------
27,660
0
-------------
40,293
0
-------------
453,558
0
-------------
0
27
Martin Purcell MBA
Chief Information Officer
(i)
(ii)
0
-------------
420,844
0
-------------
0
0
-------------
70,755
0
-------------
27,660
0
-------------
3,565
0
-------------
522,824
0
-------------
0
28
David F Duncan
System VP - Facilities Mgmt
(i)
(ii)
0
-------------
291,879
0
-------------
100
0
-------------
5,390
0
-------------
17,400
0
-------------
5,403
0
-------------
320,172
0
-------------
0
29
Jock Mccullough MD
Physician
(i)
(ii)
816,184
-------------
0
0
-------------
0
94,656
-------------
0
27,660
-------------
0
41,862
-------------
0
980,362
-------------
0
0
-------------
0
30
Daniel Stewart MD
Physician
(i)
(ii)
1,082,444
-------------
0
0
-------------
0
107,352
-------------
0
21,860
-------------
0
44,738
-------------
0
1,256,394
-------------
0
0
-------------
0
31
John Nigriny
Physician
(i)
(ii)
925,942
-------------
0
0
-------------
0
91,111
-------------
0
21,860
-------------
0
44,236
-------------
0
1,083,149
-------------
0
0
-------------
0
32
Timothy Ryken
Physician
(i)
(ii)
1,014,752
-------------
0
0
-------------
0
105,169
-------------
0
27,660
-------------
0
36,112
-------------
0
1,183,693
-------------
0
0
-------------
0
33
Matthew LeBoeuf
Physician
(i)
(ii)
867,758
-------------
0
0
-------------
0
57,254
-------------
0
13,116
-------------
0
44,248
-------------
0
982,376
-------------
0
0
-------------
0
Schedule J (Form 990) 2021
Page 3
Schedule J (Form 990) 2021
Page
3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference
Explanation
Schedule J, Part I, Line 1a Discretionary spending account
THE ORGANIZATION HAS IN PLACE A PLAN TO SUPPORT CONTINUING MEDICAL EDUCATION. THE PLAN PROVIDES FIXED DOLLAR LIMITS PER PROVIDER PER 2-YEAR PERIOD THAT CAN BE USED TO DEFRAY THE COSTS OF OBTAINING AND ATTENDING CONTINUING MEDICAL EDUCATION EVENTS AND RELATED TRAVEL. ADDITIONALLY, THESE MONIES CAN BE USED FOR PROFESSIONAL BOOKS, LICENSES, MEMBERSHIPS, AND RELATED EXPENSES. AMOUNTS MUST BE SUBMITTED FOR APPROVAL PRIOR TO REIMBURSEMENT.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
Dartmouth Hitchcock Clinic (DHC) and Mary Hitchcock Memorial Hospital (MHMH) sponsor a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable DHC and MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen to new participants in 1998. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. THE FOLLOWING INDIVIDUALS HAVE A SPLIT DOLLAR LIFE PLAN ARRANGEMENT AND RESPECTIVE EMPLOYER PREMIUMS: DANIEL JANTZEN $139,653 STEPHEN LEBLANC $63,791 RICHARD ROTHSTEIN $109,016
Schedule J, Part I, Line 3 ESTABLISHING COMPENSATION CEO
The process for determining compensation of the CEO is the responsibility of the Compensation Committee of Dartmouth Hitchcock Health (DHH). The compensation committee consists of the Chairperson of the Board and three or more members of the board who are elected by the board, acting upon the recommendation of the chairperson and are not employees of DHH, a related organization or a subsidiary organization of a related organization. The compensation committee determines the compensation of the CEO of DHC within ranges established by the board.
Schedule J, Part II NOTE REGARDING COMPENSATION
SCHEDULE J, PART II COLUMN B, PARTS I, II, AND III REPRESENT ACTUAL AMOUNTS PAID TO EMPLOYEES BY DHC AND RELATED ORGANIZATIONS. THESE AMOUNTS ARE REPORTED TO EMPLOYEES ON THEIR ANNUAL W-2 FORMS AS COMPENSATION. COLUMNS C AND D REPRESENT ITEMS EARNED, HOWEVER, NOT PAID DIRECTLY TO THE EMPLOYEE AS CASH PAYMENTS DURING THE CALENDAR YEAR. COLUMN C INCLUDES RETIREMENT BENEFITS IN A CALENDAR YEAR. COLUMN D REPRESENTS NONTAXABLE BENEFITS SUCH AS THE COST OF HEALTHCARE COVERAGE PROVIDED BY D-H ON BEHALF OF ITS EMPLOYEES.
Schedule J (Form 990) 2021
Additional Data
Software ID:
21014044
Software Version:
2021v4.2