2018-02-15T08:01:05-06:00 2017-09-30 351178661 Blue & Co LLC 500 N Meridian St Suite 200 Indianapolis IN 46204 990 2016-10-01 263083364 Deaconess Clinic Inc DEAC 8124503296 600 Mary Street Evansville IN 47747 Allen White MD Vice President 8124503296 2018-02-14 1 Carrie A Merrill CPA P00832283 3176334705 2018-02-08 38.109.186.2 2018-02-14 14:26:04 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B1F20EC9F423970385CE25A4907103D8B8C6B30C 2016 2021-01-29 14:40:06Z Allen White MD 421 Chestnut Street Evansville IN 47713 85867463 0 X deaconess.com X 2008 IN DEACONESS CLINIC WAS ORGANIZED EXCLUSIVELY FOR CHARITABLE, EDUCATION, AND SCIENTIFIC PROGRAM PURPOSES WITHIN THE MEANING OF SECTION 501(C)(3) OF THE IRS CODE WHICH INCLUDEs (AMONG OTHERS):TO DELIVER HEALTH CARE TO THE PUBLIC; TO CARRY OUT SCIENTIFIC RESEARCH AND RESEARCH PROJECTS IN THE PUBLIC INTEREST IN THE FIELDS OF MEDICAL SCIENCES, MEDICAL ECONOMICS, PUBLIC HEALTH, SOCIOLOGY, AND RELATED AREA;TO IMPROVE AND DEVELOP THE CAPABILITIES OF INDIVIDUALS AND INSTITUTIONS STUDYING, TEACHING, AND PRACTICING MEDICINE AND OTHER HEALTH OCCUPATIONS;TO PROVIDE HEALTH CARE AND HEALTH-RELATED EDUCATION FOR THE BENEFIT OF THE COMMUNITY IN A SYSTEMATIC, INTEGRATED AND COORDINATED FASHION WITH THE DEACONESS HEALTH SYSTEM AND DEACONESS HOSPITAL, INC. AND THEIR AFFILIATES. 14 1 865 0 0 0 0 0 82522900 85026554 -69564 -7790 805606 575925 83258942 85594689 0 0 0 0 79913721 85526805 0 0 0 30178617 30490980 110092338 116017785 -26833396 -30423096 18285696 19224092 16009776 23211691 2275920 -3987599 X See Sch O. 0 0 100723446 0 82771172 Patient Services Revenue-Deaconess Clinic is a major source of medical services which encompasses a broad spectrum of expertise, representing more than 20 medical and surgical specialties. Deaconess Clinic employs 114 physicians, 61 midlevel providers and 515 full time nursing and administrative full time equivalents. Deaconess Clinic serves a 25-county Tri-state area in Southwestern Indiana, Western Kentucky, and Southeastern Illinois. The clinic and its facilities have locations in Evansville, Newburgh, Mt. Vernon, Petersburg, Ft. Branch, Princeton, Oakland City, and Reo in Indiana. The Clinic also has locations in Henderson and Morganfield, Kentucky. The Clinics served 658,606 patient visits from October 1, 2016 through September 2017. 2991750 0 2255382 THE RESEARCH INSTITUTE OF DEACONESS CLINIC ASSISTS DEACONESS CLINIC'S MORE THAN 140+ PHYSICIANS, AS WELL AS OTHER PHYSICIANS THROUGHOUT THE COMMUNITY IN GAINING ACCESS TO LEADING EDGE MEDICAL SCIENCE AND NEW TREATMENTS FOR ACUTE AND CHRONIC ILLNESSES. THE INSTITUTE WAS AWARDED 29 NEW AND EXPANDED CLINICAL RESEARCH GRANTS THIS YEAR TO STUDY INVESTIGATIONAL DRUGS AND DEVICES ACROSS 9 FIELDS OF MEDICINE INCLUDING, BUT NOT LIMITED TO, NEW TREATMENTS FOR heart disease, depression, diabetes, autism, chronic migraines, COPD, actinic keratosis, rosacea, severe asthma. weight loss, peanut allergy, and hypercholesterolemia. THE NEW RESEARCH GRANTS PROVIDED TREATMENT OPPORTUNITES AND PREVENTATIVE HEALTH SERVICES FOR 353 PATIENTS. IN ALL, THE NEWLY AWARDED GRANTS THIS YEAR TOTALED $3.2 MILLION TO COVER [CONTINUATION FROM PAGE 2] THE COSTS ASSOCIATED WITH THE CONDUCT OF THE CLINICAL TRIALS WITHIN THE REGION. 323 patients were screened for clinical trial qualification throughout the year, with 238 new PATIeNTS ENROLLED oNTO CLINICAL protocals, RESULTING IN 3,291 RESEARCH RELATED PATIENT VISITS. The research institute launched its new cancer research initiative with cancer research affiliations with the Carle Cancer Center and MD Anderson. The initiative enables Deaconess patinets to gain access to advance cancer treatments through the National Cancer Institute's National Community Oncology Program and the NCI Match Program. THE INSTITUTE OVERSAW THE TRAINING OF three NEW CLINICAL INVESTIGATORS IN 2017, INCLUDING THEIR RESEARCH CERTIFICATIONS IN GOOD CLINICAL PRACTICE AND THE PROTECTION OF HUMAN SUBJECTS. 103715196 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 101 0 1 865 1 0 0 0 0 0 0 0 0 0 0 X 14 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 IN X richard perry 8124502370 600 Mary Street Evansville IN 47747 Stephen TITZER CHAIRMAN 5.00 10.00 X X 2000 4800 0 Cheryl Wathen Secretary/Treasurer 5.00 60.00 X X 0 587003 155289 Maqbool AHMED MD director 50.00 10.00 X 958941 5200 43293 Jon C Davis MD Director 50.00 0.00 X 1544034 0 37497 steven etherton md director 50.00 0.00 X 304522 0 45993 Rachel Farmer MD Director 50.00 0.00 X 203837 0 33754 RM Galen MD director 50.00 0.00 X 320673 0 36265 Mia Hindi MD Director 50.00 0.00 X 1119220 14100 42933 Majed Koleilat MD director 50.00 0.00 X 874109 0 42991 Barry Phillips MD director 50.00 10.00 X 421022 13180 38441 James R Porter MD Director 5.00 50.00 X 0 701890 164315 Bradley Scheu MD Director 50.00 0.00 X 395795 0 40529 William Smith MD director 50.00 0.00 X 292356 0 22514 Linda White director 5.00 60.00 X 0 1683301 193418 Youssef SIAGE md Director (10/16 - 03/17) 50.00 0.00 X 71729 0 1128 W Allen WHITE MD Non-voting Direct/ Vice Pr 50.00 0.00 X X 421548 0 127150 Julie DINGMAN Operations Administrator 50.00 0.00 X 181562 0 35333 Joseph Klink MD physician 50.00 0.00 X 970391 0 45284 Manga D Kodali MD physician 50.00 0.00 X 937077 0 15391 Shaukat Iftikhar MD physician 50.00 0.00 X 1095662 0 39437 Bruce Schneider MD physician 50.00 0.00 X 1415586 0 53092 Jason White MD physician 50.00 0.00 X 905640 0 39429 12435704 3009474 1253476 147 0 1 0 The Advisory Board Company PO BOx 79461 Baltimore MD 212790461 consulting 304237 weatherby Locums inc PO Box 972633 Dallas TX 753972633 locums 266248 Key Construction 2316 Glenview Drive Evansville IN 47720 Construction 200050 Scribe America LLC 1200 E Los Olas Blvd Suite 1 201 Ft Lauderdale FL 33001 Scribe Service 123493 The State Group 13800 N Hwy 57 Evansville IN 47725 service 105668 6 Net Patient Revenue 621110 82771172 82771172 Net Research Revenue 621110 2255382 2255382 85026554 274012 264984 9028 9028 9028 7790 -7790 -7790 -7790 USI Capitation 900099 437269 437269 EHR Revenue 900099 129628 129628 566897 85594689 85026554 0 568135 7929195 7375303 553892 64951682 60976126 3975556 5910992 5621223 289769 3210820 3053419 157401 3524116 3351357 172759 426768 426768 18629 18629 7869934 2167677 5702257 339197 171978 167219 8667761 8667761 858603 825313 33290 9419808 9419808 82164 64106 18058 630072 406798 223274 10 10 886631 806260 80371 1291403 808057 483346 116017785 103715196 12302589 0 8902323 9951924 746397 502927 11114944 5926740 4882988 5188204 3753988 3581037 18285696 19224092 16009776 23211691 16009776 23211691 X 2275920 -3987599 2275920 -3987599 18285696 19224092 X -30423096 24159577 X X 0 1 X 1 0 X Schedule A, Line 3: DEACONESS CLINIC HAS BEEN DETERMINED BY THE IRS TO BE A PUBLIC CHARITY UNDER IRS CODE SECTION 170(B)(1)(A)(III). PER SCHEDULE H INSTRUCTIONS ONLY ORGANIZATIONS THAT OPERATE AT LEAST ONE FACILITY THAT IS, OR IS REQUIRED TO BE, LICENSED, REGISTERED, OR SIMILARILY RECOGNIZED BY A STATE AS A HOSPITAL IS REQUIRED TO COMPLETE THE SCHEDULE. THE CLINIC IS NOT LICENSED AS A HOSPITAL FOR THE STATE OF INDIANA. 0 0 0 0 0 0 0 0 1 18629 18629 0 Part II-B, Line 1: Lobbying expenditures consisted of a portion of membership dues to professional organizations in which Deaconess Clinic and its employees are members. The lobbying portion of the dues is noted on the membership application or billing statement. 4823163 2226814 2596349 6101020 3699926 2401094 190761 190761 5188204 DUE FROM RELATED ORGANIZATION 1530735 INVESTMENTS IN JOINT VENTURES 87924 INTANGIBLES 305331 457 Plan 1657047 3581037 X Part X, Line 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2017 AND 2016, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. Part XI and XII: Sections are not required as the organization is part of a consolidated financial statement. The consolidated financial statement is audited by an independent accounting firm and is prepared in accordance with generally accepted accounting principles. X 1 0 X X X X X X 0 1 0 0 0 0 0 0 0 Cheryl Wathen Secretary/Treasurer 0 447811 0 124304 0 14888 0 119938 0 35351 0 742292 0 0 Maqbool AHMED MD director 897209 0 60005 0 1727 5200 18705 0 24588 0 1002234 5200 0 0 Jon C Davis MD Director 1300951 0 227673 0 15410 0 14590 0 22907 0 1581531 0 0 0 steven etherton md director 256851 0 46297 0 1374 0 22820 0 23173 0 350515 0 0 0 Rachel Farmer MD Director 174889 0 27112 0 1836 0 10849 0 22905 0 237591 0 0 0 RM Galen MD director 241699 0 77008 0 1966 0 18705 0 17560 0 356938 0 0 0 Mia Hindi MD Director 1049319 0 66692 0 3209 14100 14590 0 28343 0 1162153 14100 0 0 Majed Koleilat MD director 795383 0 76008 0 2718 0 18705 0 24286 0 917100 0 0 0 Barry Phillips MD director 344157 0 74735 0 2130 13180 15226 0 23215 0 459463 13180 0 0 James R Porter MD Director 0 495340 0 135940 0 70610 0 135172 0 29143 0 866205 0 64229 Bradley Scheu MD Director 298839 0 87768 0 9188 0 14590 0 25939 0 436324 0 0 0 William Smith MD director 211060 0 72649 0 8647 0 14590 0 7924 0 314870 0 0 0 Linda White director 0 760682 0 291040 0 631579 0 181508 0 11910 0 1876719 0 595863 W Allen WHITE MD Non-voting Direct/ Vice Pr 325969 0 90222 0 5357 0 95480 0 31670 0 548698 0 0 0 Julie DINGMAN Operations Administrator 156546 0 23638 0 1378 0 17949 0 17384 0 216895 0 0 0 Joseph Klink MD physician 913053 0 47782 0 9556 0 14590 0 30694 0 1015675 0 0 0 Manga D Kodali MD physician 890897 0 37500 0 8680 0 14590 0 801 0 952468 0 0 0 Shaukat Iftikhar MD physician 1012313 0 69723 0 13626 0 14590 0 24847 0 1135099 0 0 0 Bruce Schneider MD physician 1291089 0 60902 0 63595 0 28245 0 24847 0 1468678 0 0 59932 Jason White MD physician 829367 0 73849 0 2424 0 14590 0 24839 0 945069 0 0 0 Part I, Line 1a Social club dues are paid for Linda White for organization business only. Any personal use of the club must be paid by the employee. Part I, Line 4b SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS: SEVERANCE NONQUALIFIED EQUITY-BASED CHERYL WATHEN $ -0- $ 18,000 $ -0- BRADLEY SCHEU, MD 0 18,000 0 Joseph Klink, MD 0 18,000 0 LINDA WHITE 0 18,000 0 W. ALLEN WHITE, MD 0 18,000 0 MAQBOOL AHMED, MD 0 18,000 0 MAJED KOLEILAT, MD 0 18,000 0 Jason White, MD 0 18,000 0 JAMES R. PORTER 0 18,000 0 BRUCE SCHNEIDER, MD 0 18,000 0 MIA HINDI, MD 0 18,000 0 MANGA KODALI, MD 0 18,000 0 PART 1, LINE 4B: CHERYL WATHEN: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $91,487. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $0. JAMES PORTER: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $105,587. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $64,229. LINDA WHITE: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $140,589. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $414,631. William White: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $59,136. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $0. Jung Wook Kang Smith Family of Bd Mbr 209235 Compensation 0 Sch L, Part IV Dr. Jung Wook Kang Smith is married to Dr. William Smith, a board member of Deaconess Clinic, Inc. She is an employed physician at Deaconess Clinic, Inc. Form 990, Part VI, Section A, line 6 CLASSES OF MEMBERS OR STOCKHOLDERS: DEACONESS HEALTH SYSTEM, INC., A TAX EXEMPT 501(c)(3) organization, IS THE SOLE CORPORATE MEMBER OF DEACONESS CLINIC, INC. Form 990, Part VI, Section A, line 7a ELECTION OF MEMBERS AND THEIR RIGHTS: DEACONESS HEALTH SYSTEM, INC. MUST APPROVE THE selected DEACONESS CLINIC Vice President. Form 990, Part VI, Section A, line 7b Governance Decisions: APPOINTMENT OF the Vice President REQUIRES APPROVAL OF THE Sole Corporate MEMBER; and, CHANGES TO the PHYSICIAN COMPENSATION PLAN REQUIRES THE APPROVAL OF THE Sole Corporate MEMBER THROUGH ITS COMPENSATION COMMITTEE WHICH IS COMPRISED OF INDEPENDENT MEMBERS OF THE DEACONESS HEALTH SYSTEM BOARD. Form 990, Part VI, Section B, line 11b The process that Deaconess Clinic utilizes to present the form 990 to its governing body prior to filing is to present the form 990 to the Controller, CFO and CEO of the organization for review. After this review is performed and all questions are answered, the form 990 is presented to the Board of Directors of Deaconess Health System at the board meeting prior to the filing date of the form 990. Any additional questions are answered and the final filing is then completed. Form 990, Part VI, Section B, line 12c Conflict of interest review and compliance activities are conducted throughout the year under the direction of Deaconess Hospital's corporate compliance officer. Upon appointment, and annually thereafter, officers, directors, trustees, and key employees, also known as interested persons, are required to complete "the conflicts of interest questionnaire and/or the "the disclosure questionnaire". These documents serve to ensure interested persons or committee members with board delegated powers have an appropriate and timely manner in which to disclose any potential conflicts. Conflicts are considered with respect to outside interest, investments, outside activities, and business interests among the interested persons as well as their family members. On a periodic basis, reviews occur to ensure Deaconess Clinic operates in a manner consistent with its charitable purpose. Subjects that are reviewed on a periodic basis include compensation, physician relationships, partnership and joint venture arrangements. Form 990, Part VI, Section B, line 15a Compensation for Top Officials and other Officers: Salaries and benefits of officers and physicians at Deaconess Clinic are approved by the Deaconess Health System Compensation committee. Deaconess Clinic Board can only make recommendation to the Deaconess Health System Compensation Committee. The compensation committee is appointed by the Board of Directors of Deaconess Health System Inc. and must meet the independence requirements of the SEC. The committee has the power and authority to: 1. annually review, approve, and recommend to the Board of Directors for its final approval for the Vice President and each other executive officers all elements of executive compensation. 2. monitor broadly the structure, philosophy or competitiveness of the system's general hiring or compensation practices. 3. oversee the establishment and administration of the company's broad-based benefit plans and programs. 4. review or approve significant amendments or changes to the plans and programs. 5. retain and terminate any compensation consultant to be used to assist in the evaluation of director, Vice President or executive office compensation. 6. sole authority to approve the consultant's fees and other retention terms. 7. obtain advice and assistance from internal or external legal, accounting or other advisors. 8. approve all physician and physician-related contracts. 9. make regular reports to the board. Form 990, Part VI, Section C, line 19 Deaconess Clinic's articles of incorporation are available on the Secretary of State's website. As required by law, Deaconess Clinic submits its consolidated financial statements to the Indiana Department of Health which are published on its website. Governing documents, aside from the articles of incorporation, and the conflict of interest policy are not available for public inspection. Form 990, Part XI, line 9: CAPITAL CONTRIBUTED 24,159,577. Form 990, Part XII, line 2c, Oversight of Audit: The board of directors assumes responsibility for oversight of the audit of the financial statements and selection of the independent accountant; and no processes have changed from prior year. 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