2019-05-13T16:37:34-05:00 2018-06-30 861065772 Deloitte Tax LLP 200 Renaissance Center Suite 3900 Detroit MI 49243 990 2017-07-01 311459815 CHMC Community Health Services Network CHMC 5138031106 3333 Burnet Avenue Cincinnati OH 452293039 Mark Mumford Director and Treasurer 5138031106 2019-05-13 1 Alicia Janisch P00741382 3133963000 167.219.88.140 2019-05-13 13:43:02 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B457E39100F69F1025E0AC0752F4D60A204E3628 2017 2019-02-21 02:37:17Z Steve Davis 3333 Burnet Avenue Cincinnati OH 452293039 3637859 0 X N/A X 1995 OH Provide medical services to children in the community. 4 0 0 0 0 0 0 0 4210315 3579251 0 0 181532 58608 4391847 3637859 0 0 0 0 2515259 0 0 0 0 1549874 3919271 4065133 3919271 326714 -281412 1519893 2044543 -1020668 -214606 2540561 2259149 X CHMC Community Health Services Network ("CHSN") is organized and operated exclusively to support Cincinnati Children's Hospital Medical Center ("CCHMC") in CCHMC's efforts to provide medical services to all of the children in the community. 0 0 3919271 3637859 Cincinnati Children's Hospital Medical Center ("CCHMC") is devoted to providing medical services to all of the children in the community. CHMC Community Health Services Network ("CHSN") is organized and operated exclusively to support CCHMC in this effort by reaching out to the medically underserved and economically disadvantaged neighborhoods of our community.CHSN serves as the structure for bringing medical professionals who share the vision of providing quality medical care to the underprivileged and underserved. CHSN carries out its charitable purposes by seeking and hiring such "mission oriented physicians. In addition, CHSN will make medical professionals an integral part of these underprivileged neighborhoods by establishing sites within these communities where resident physicians will work. The resident physicians will be able to learn more about the patients they seek to serve and thereby provide better service to them. Furthermore, in order to ensure its goals are met, CHSN will act as a liaison between the neighborhoods and CCHMC, and will focus on how to best meet the difficult and unique needs of the underprivileged neighborhoods of our community. 3919271 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 0 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 0 0 0 0 X Michael Bauer 5138031106 3333 Burnet Avenue Cincinnati OH 452293039 X Steve Davis Chairman and President 1.00 49.00 X X 0 818376 154903 Mark Mumford Director and Treasurer 1.00 49.00 X X 0 874224 274175 Michael Fisher Director 1.00 49.00 X 0 2161175 237395 Tom Dewitt MD Director 1.00 49.00 X 0 324536 48447 Charlene Mason through 1017 Secretary 1.00 49.00 X 0 310169 56316 Scott J Hamlin Former Director 0.00 0.00 X 0 500000 0 0 4988480 771236 0 1 1 0 0 Net Patient Revenues 621990 3579251 3579251 3579251 58608 58608 58608 3637859 3637859 0 0 67700 67700 199109 199109 17818 17818 167068 167068 Allocated Sal & Ben 2453494 2453494 Patient Care Supplies 492221 492221 Collection Fees 360315 360315 Telephone 72572 72572 88974 88974 3919271 3919271 0 0 353025 1138851 512005 379188 2933 0 1194334 667830 651930 526504 1519893 2044543 -1020668 -214606 -1020668 -214606 X 2540561 2259149 2540561 2259149 1519893 2044543 -281412 0 X X 0 1 X 0 0 X 3356919 4025071 3923029 4210315 3579251 19094585 3356919 4025071 3923029 4210315 3579251 19094585 0 0 0 19094585 85520 74840 157983 181532 58608 558483 3442439 4099911 4081012 4391847 3637859 19653068 0.97160 0.97240 0.00000 X 68879 68879 723729 381463 342266 401726 286367 115359 526504 X Part X, Line 2: From the consolidated audited financial statements of Children's Hospital Medical Center, which include the activity of CHMC Community Health Service Network: Cincinnati Children's accounts for income taxes in accordance with Accounting Standards Codification Topic ("ASC") 740 "Income Taxes". It is Cincinnati Children's policy to classify the expense related to interest and penalties, if any, to be paid on underpayments of income taxes within other expenses. There were no material penalties or interest recognized in fiscal year 2018. Listed below are the tax years that remain subject to examination by major tax jurisdiction: Federal - 2015 - 2018 State - 2015 - 2018 0 1 0 0 0 0 0 0 0 Steve Davis Chairman and President 0 602528 0 214558 0 1290 0 123148 0 31755 0 973279 0 0 Mark Mumford Director and Treasurer 0 559208 0 202658 0 112358 0 242601 0 31574 0 1148399 0 81436 Michael Fisher Director 0 998067 0 777212 0 385896 0 205821 0 31574 0 2398570 0 336885 Tom Dewitt MD Director 0 320096 0 630 0 3810 0 27000 0 21447 0 372983 0 0 Charlene Mason through 1017 Secretary 0 227499 0 60477 0 22193 0 41245 0 15071 0 366485 0 0 Scott J Hamlin Former Director 0 0 0 0 0 500000 0 0 0 0 0 500000 0 0 Part I, Line 3 CHMC Community Health Services Network relied on Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"), a related organization, to establish the compensation of individuals listed on Form 990, Part VII. Cincinnati Children's used the methods described below: - Compensation Committee - Independent Compensation Consultant - Form 990 of other organizations - Compensation survey or study - Approval by the Board or Compensation Committee Part I, Line 4b Certain officers and key employees of Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"), a related organization to CHSN, have arrangements which provide for supplemental retirement benefits as described in IRC Sec. 457(f). Due to the substantial risk of forfeiture provision, these arrangements are non-vested and there is no guarantee that these officers and faculty members will ever receive these benefits. The following is a listing of officers and key employees that received a payment under Cincinnati Children's IRC Sec. 457(f) plan during the year: 1. Michael Fisher - $336,885 2. Mark Mumford - $81,436 Form 990, Schedule J: Scott Hamlin left Cincinnati Children's in April 2015. In connection with his departure, he received in July 2017 a payout based on meeting certain requirements. Form 990, Schedule J: Explanation of benefits: All compensation and benefits reported on Form 990, Part VII and Schedule J, Part II are provided by Cincinnati Children's, a related entity to CHSN. The employee benefit plan contribution amounts listed on Schedule J, Part II may include one or more of the following benefits: 1. Elective employee deferrals under IRC Sec. 403(b) 2. Discretionary employer contributions under IRC Sec. 403(b) 3. Elective employee deferrals under IRC Sec. 457(b) 4. Elective employee deferrals under IRC Sec. 457(f) In addition to the retirement plan contributions disclosed on Form 990, Part VII and Schedule J, Part II, the following non-taxable employee welfare benefits were made available to the employed, compensated officers and key employees listed on Form 990, Part VII and Schedule J, Part II: 1. Health and dental insurance benefits 2. Group life insurance (portions of which are taxed) 3. Unemployment benefits 4. Disability benefits The officers and key employees listed on Form 990, Part VII and Schedule J, Part II are also eligible for any other available employee benefits. Form 990, Part VI, Section A, line 6 Article III of CHSN's Code of Regulations provides that Children's Hospital Medical Center, a related organization, possesses the authority to appoint, elect, and remove members of CHSN's Board of Trustees. Form 990, Part VI, Section A, line 7a Article III of CHSN's Code of Regulations provides that Children's Hospital Medical Center, a related organization, possesses the authority to appoint, elect, and remove members of CHSN's Board of Trustees. Form 990, Part VI, Section B, line 11b The CHMC Community Health Services Network ("CHSN") Form 990 is prepared by senior management from Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"), a related organization. External tax consultants then review Form 990 for completeness and accuracy. The Form 990 is then made available to all CHSN Board Members in advance of filing. Form 990, Part VI, Section B, line 12c All of CHSN's Board Members receive an annual questionnaire requesting information regarding family and business relationships that could potentially result in a conflict of interest under CHSN's Conflict of Interest Policy. Once the questionnaires have been completed by all of CHSN's Board Members, the questionnaires are reviewed and if CHSN determines that a relationship exists that presents a conflict of interest, CHSN follows the provisions set forth in CHSN's Conflict of Interest Policy to resolve the conflict and determines the appropriate reporting to the board and, if required, Form 990 disclosure. Form 990, Part VI, Section B, line 15 CHSN's Board Members and Officers are employed by Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"), a related organization. Cincinnati Children's has a Compensation Committee that annually reviews the recommendations of Cincinnati Children's management regarding employee performance evaluation and compensation adjustments for disqualified persons to ensure that Cincinnati Children's has complied with the provisions of the rebuttable presumption of reasonableness under IRC Sec. 4958. Form 990, Part VI, Section C, line 19 CHSN's governing documents, Conflict of Interest Policy, and financial statements are maintained on file by Cincinnati Children's senior management and are available to the public upon request either in-person, by telephone, or by written request. Form 990, Part VI, Section B, Question 13: CHSN's Board of Trustees has not formally adopted a written Whistleblower Policy. However, CHSN is a related organziation of Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"). Cincinnati Children's has a written Whistleblower Policy and CHSN abides by the provisions of this Policy. Form 990, Part VI, Section B, Question 14: CHSN's Board of Trustees has not formally adopted a written Document Retention and Destruction Policy. However, CHSN is a related organization of Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"). Cincinnati Children's has a written Document Retention and Destruction Policy and CHSN abides by the provisions of this Policy. Form 990, Part VII, Section A: All individuals listed on Form 990, Part VII are employed by Cincinnati Children's Hospital Medical Center ("Cincinnati Children's"), a related organization. Each individual devotes an average of 50 hours/week for their duties to Cincinnati Children's and affiliated entities. Form 990, Part XII, Line 2b: CHSN's financial statements are included as part of the Cincinnati Children's Hospital Medical Center & Affiliates consolidated financial statement audit. Children's Hospital Medical Center 3333 Burnet Avenue Cincinnati OH 45229 310833936 Pediatric Healthcare OH 501(c)(3) 3 The Children's Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 Children's Hospital Medical Center R 2251555 Cash Form 990, Schedule R, Part V: During the time period covered by this return, CHMC Community Health Services Network received certain accounting and administrative services from Cincinnati Children's Hospital Medical Center at no cost. The value of these services is an unspecified amount.