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CANTON-POTSDAM MEDICAL PRACTICE PLLC: Form 990, tax year 2016

View the entire original 990 at ProPublica ↗

Organization
CANTON-POTSDAM MEDICAL PRACTICE PLLC (EIN 46-0714367)
Tax period
2016-01-01 to 2016-12-31
Filed
2017-11-06
IRS object ID
201723109349300342
Schema version
2016v3.0
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2017-11-06T09:45:54-05:00ReturnTs
Tax Period End2016-12-31TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

FieldValueIRS element (for citing)
Preparer Firm EIN822624857PreparerFirmEIN

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1GRAY & GRAY AND ASSOCIATES CPAS PCBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line11 MAIN STREET SUITE 101AddressLine1Txt
CityCANTONCityNm
State AbbreviationNYStateAbbreviationCd
ZIP136171277ZIPCd
FieldValueIRS element (for citing)
Return Type990ReturnTypeCd
Tax Period Begin2016-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN460714367EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1CANTON-POTSDAM MED PRACTICE PLLCBusinessNameLine1Txt
FieldValueIRS element (for citing)
Business Name ControlCANTBusinessNameControlTxt
Phone3152615100PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line150 LEROY STREETAddressLine1Txt
CityPOTSDAMCityNm
State AbbreviationNYStateAbbreviationCd
ZIP13676ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonROBERT T ROGERSII MDPersonNm
Person TitleDIRECTORPersonTitleTxt
Phone3152615100PhoneNum
Signature2017-09-01SignatureDt
Discuss With Paid PreparerYes (true)DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonJOHN J GRAY JR CPAPreparerPersonNm
PTINP00076464PTIN
Phone3153862925PhoneNum
Preparation2017-11-06PreparationDt

Filing Security Information FilingSecurityInformation

FieldValueIRS element (for citing)
At Submission Creation Device Id35D3879163D6E86CE39169CEF1932A0DEFAB2344AtSubmissionCreationDeviceId
At Submission Filing Device Id2D426263845748513852DCBD2BD9A71A3091F1FAAtSubmissionFilingDeviceId
FieldValueIRS element (for citing)
Tax2016TaxYr
Build TS2018-03-14 21:41:22ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Principal OfficerROBERT T ROGERSII MDPrincipalOfficerNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line150 LEROY STREETAddressLine1Txt
CityPOTSDAMCityNm
State AbbreviationNYStateAbbreviationCd
ZIP13676ZIPCd
FieldValueIRS element (for citing)
Gross Receipts$3,891,066GrossReceiptsAmt
Group Return For AffiliatesfalseGroupReturnForAffiliatesInd
Organization501c3Yes (X)Organization501c3Ind
Website AddressN/AWebsiteAddressTxt
Type Of Organization OtherYes (X)TypeOfOrganizationOtherInd
Other Organization DscPLLCOtherOrganizationDsc
Formation2012FormationYr
Legal Domicile StateNYLegalDomicileStateCd
Activity Or MissionCANTON-POTSDAM MEDICAL PRACTICE'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE PHYSICIAN SERVICES, IN AN OUTPATIENT CLINIC SETTING, THAT PROVIDE PUBLIC BENEFIT TO THE COMMUNITY AND CANTON-POTSDAM HOSPITAL.ActivityOrMissionDesc
Voting Members Governing Body1VotingMembersGoverningBodyCnt
Voting Members Independent0VotingMembersIndependentCnt
Total Employee0TotalEmployeeCnt
Total Gross UBI$0TotalGrossUBIAmt
CY Contributions Grants$0CYContributionsGrantsAmt
PY Program Service Revenue$3,295,263PYProgramServiceRevenueAmt
CY Program Service Revenue$3,879,270CYProgramServiceRevenueAmt
CY Investment Income$0CYInvestmentIncomeAmt
PY Other Revenue$31PYOtherRevenueAmt
CY Other Revenue$11,796CYOtherRevenueAmt
PY Total Revenue$3,295,294PYTotalRevenueAmt
CY Total Revenue$3,891,066CYTotalRevenueAmt
CY Grants And Similar Paid$0CYGrantsAndSimilarPaidAmt
CY Benefits Paid To Members$0CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid$4,062,450PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid$5,785,313CYSalariesCompEmpBnftPaidAmt
CY Total Prof Fndrsng Expns$0CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense$0CYTotalFundraisingExpenseAmt
PY Other Expenses$1,474,576PYOtherExpensesAmt
CY Other Expenses$1,268,532CYOtherExpensesAmt
PY Total Expenses$5,537,026PYTotalExpensesAmt
CY Total Expenses$7,053,845CYTotalExpensesAmt
PY Revenues Less Expenses-$2,241,732PYRevenuesLessExpensesAmt
CY Revenues Less Expenses-$3,162,779CYRevenuesLessExpensesAmt
Total Assets BOY$1,108,417TotalAssetsBOYAmt
Total Assets EOY$1,021,400TotalAssetsEOYAmt
Total Liabilities BOY$27,354TotalLiabilitiesBOYAmt
Total Liabilities EOY$111,347TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY$1,081,063NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY$910,053NetAssetsOrFundBalancesEOYAmt
Info In Schedule O Part IIIYes (X)InfoInScheduleOPartIIIInd
MissionCANTON-POTSDAM MEDICAL PRACTICE'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE PHYSICIAN SERVICES, IN AN OUTPATIENT CLINIC SETTING, THAT PROVIDE PUBLIC BENEFIT TO THE COMMUNITY AND CANTON-POTSDAM HOSPITAL.MissionDesc
Significant New Program SrvcfalseSignificantNewProgramSrvcInd
Significant ChangefalseSignificantChangeInd
Expense$1,079,143ExpenseAmt
Revenue$1,076,350RevenueAmt
DescCANTON-POTSDAM MEDICAL PRACTICE OPERATED A GENERAL SURGERY CLINIC IN 2016. PATIENT VISITS TOTALED APPROXIMTELY 1,029. THIS CLINIC OPENED IN AUGUST OF 2014 AND SERVES THE SURROUNDING NORTH COUNTRY COMMUNITIES OF (AND INCLUDING) POTSDAM, NEW YORK.Desc

Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp

FieldValueIRS element (for citing)
Expense$1,065,226ExpenseAmt
Revenue$2,575,235RevenueAmt
DescCANTON-POTSDAM MEDICAL PRACTICE OPERATED AN URGENT CARE CENTER IN 2016. PATIENT VISITS TOTALED APPROXIMATELY 13,468. THE URGENT CARE CENTER OPENED IN MARCH OF 2014 AND SERVES THE SURROUNDING NORTH COUNTRY COMMUNITIES OF (AND INCLUDING) POTSDAM, NEW YORK.Desc

Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp

FieldValueIRS element (for citing)
Expense$1,025,500ExpenseAmt
Revenue$1,117,471RevenueAmt
DescCANTON-POTSDAM MEDICAL PRACTICE OPERATED AN ORTHOPEDIC CLINIC IN 2016. PATIENT VISITS TOTALED APPROXIMATELY 2,541. THE CLINIC OPENED IN FEBRUARY OF 2016 AND SERVES THE SURROUNDING NORTH COUNTRY COMMUNITIES OF (AND INCLUDING) POTSDAM, NEW YORK.Desc

Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp

FieldValueIRS element (for citing)
Expense$3,382,997ExpenseAmt
Revenue$6,275,588RevenueAmt
DescCANTON-POTSDAM MEDICAL PRACTICE OPERATES OTHER OUTPATIENT CLINIC LOCATIONS INCLUDING THE FOLLOWING: ENT: LOCATED IN POTSDAM, NY, THIS CLINIC SERVED APPROXIMATELY 3,138 PATIENTS IN 2016. GASTRO: LOCATED IN MASSENA, NY, THIS CLINIC SERVED APPROXIMATELY 3,460 PATIENTS IN 2016. FAMILY PRACTICE: LOCATED IN COLTON, NY, THIS CLINIC SERVED APPROXIMATELY 2,561 PATIENTS IN 2016. CANTON GENERAL SURGERY: LOCATED IN CANTON, NY, THIS CLINIC OPENED IN JANUARY 2016 AND SERVED APPROXIMATELY 936 PATIENTS IN 2016.Desc
FieldValueIRS element (for citing)
Total Other Prog Srvc Expense$3,382,997TotalOtherProgSrvcExpenseAmt
Total Other Prog Srvc Revenue$6,275,588TotalOtherProgSrvcRevenueAmt
Total Program Service Expenses$6,552,866TotalProgramServiceExpensesAmt
Described In Section501c3Yes (true)DescribedInSection501c3Ind
Schedule B RequiredfalseScheduleBRequiredInd
Political Campaign ActyfalsePoliticalCampaignActyInd
Lobbying ActivitiesfalseLobbyingActivitiesInd
Subject To Proxy TaxfalseSubjectToProxyTaxInd
Donor Advised FundfalseDonorAdvisedFundInd
Conservation EasementsfalseConservationEasementsInd
Collections Of ArtfalseCollectionsOfArtInd
Credit CounselingfalseCreditCounselingInd
Temp Or Permanent EndowmentsfalseTempOrPermanentEndowmentsInd
Report Land Building EquipmentYes (true)ReportLandBuildingEquipmentInd
Report Investments Other SecfalseReportInvestmentsOtherSecInd
Report Program Related InvstfalseReportProgramRelatedInvstInd
Report Other AssetsfalseReportOtherAssetsInd
Report Other LiabilitiesfalseReportOtherLiabilitiesInd
Include FIN48 FootnoteYes (true)IncludeFIN48FootnoteInd
Independent Audit Fincl StmtfalseIndependentAuditFinclStmtInd
Consolidated Audit Fincl StmtYes (true)ConsolidatedAuditFinclStmtInd
School OperatingfalseSchoolOperatingInd
Foreign OfficefalseForeignOfficeInd
Foreign ActivitiesfalseForeignActivitiesInd
More Than5000 K To OrgfalseMoreThan5000KToOrgInd
More Than5000 K To IndividualsfalseMoreThan5000KToIndividualsInd
Professional FundraisingfalseProfessionalFundraisingInd
Fundraising ActivitiesfalseFundraisingActivitiesInd
Gaming ActivitiesfalseGamingActivitiesInd
Operate HospitalfalseOperateHospitalInd
Grants To OrganizationsfalseGrantsToOrganizationsInd
Grants To IndividualsfalseGrantsToIndividualsInd
Schedule J RequiredYes (true)ScheduleJRequiredInd
Tax Exempt BondsfalseTaxExemptBondsInd
Engaged In Excess Benefit TransfalseEngagedInExcessBenefitTransInd
PY Excess Benefit TransfalsePYExcessBenefitTransInd
Loan OutstandingfalseLoanOutstandingInd
Grant To Related PersonfalseGrantToRelatedPersonInd
Business Rln With Org MemfalseBusinessRlnWithOrgMemInd
Business Rln With Fam MemfalseBusinessRlnWithFamMemInd
Business Rln With Officer EntfalseBusinessRlnWithOfficerEntInd
Deductible Non Cash ContrifalseDeductibleNonCashContriInd
Deductible Art ContributionfalseDeductibleArtContributionInd
Terminate OperationsfalseTerminateOperationsInd
Partial LiquidationfalsePartialLiquidationInd
Disregarded EntityfalseDisregardedEntityInd
Related EntityYes (true)RelatedEntityInd
Related Organization Ctrl EntfalseRelatedOrganizationCtrlEntInd
Trnsfr Exmpt Non Chrtbl Rltd OrgfalseTrnsfrExmptNonChrtblRltdOrgInd
Activities Conducted PrtshpfalseActivitiesConductedPrtshpInd
Schedule O RequiredYes (true)ScheduleORequiredInd
IRP Document18IRPDocumentCnt
IRP Document W2 G0IRPDocumentW2GCnt
Backup Wthld ComplianceYes (true)BackupWthldComplianceInd
Employee0EmployeeCnt
Unrelated Bus Incm Over LimitfalseUnrelatedBusIncmOverLimitInd
Foreign Financial AccountfalseForeignFinancialAccountInd
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTransInd
Taxable Party NotificationfalseTaxablePartyNotificationInd
Nondeductible ContributionsfalseNondeductibleContributionsInd
Indoor Tanning ServicesfalseIndoorTanningServicesInd
Info In Schedule O Part VIYes (X)InfoInScheduleOPartVIInd
Governing Body Voting Members1GoverningBodyVotingMembersCnt
Independent Voting Member0IndependentVotingMemberCnt
Family Or Business RlnfalseFamilyOrBusinessRlnInd
Delegation Of Mgmt DutiesYes (true)DelegationOfMgmtDutiesInd
Change To Org DocumentsfalseChangeToOrgDocumentsInd
Material Diversion Or MisusefalseMaterialDiversionOrMisuseInd
Members Or StockholdersfalseMembersOrStockholdersInd
Election Of Board MembersfalseElectionOfBoardMembersInd
Decisions Subject To ApprovafalseDecisionsSubjectToApprovaInd
Minutes Of Governing BodyYes (true)MinutesOfGoverningBodyInd
Minutes Of CommitteesfalseMinutesOfCommitteesInd
Officer Mailing AddressfalseOfficerMailingAddressInd
Local ChaptersfalseLocalChaptersInd
Form990 Provided To Gvrn BodyYes (true)Form990ProvidedToGvrnBodyInd
Conflict Of Interest PolicyYes (true)ConflictOfInterestPolicyInd
Annual Disclosure Covered PrsnYes (true)AnnualDisclosureCoveredPrsnInd
Regular Monitoring EnfrcYes (true)RegularMonitoringEnfrcInd
Whistleblower PolicyYes (true)WhistleblowerPolicyInd
Document Retention PolicyYes (true)DocumentRetentionPolicyInd
Compensation Process CEOYes (true)CompensationProcessCEOInd
Compensation Process OtherYes (true)CompensationProcessOtherInd
Investment In Joint VenturefalseInvestmentInJointVentureInd
Upon RequestYes (X)UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1CANTON-POTSDAM HOSPITALBusinessNameLine1Txt
FieldValueIRS element (for citing)
Phone3152615100PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line150 LEROY STREETAddressLine1Txt
CityPOTSDAMCityNm
State AbbreviationNYStateAbbreviationCd
ZIP13676ZIPCd

Form990 Part VII Section A Form990PartVIISectionAGrp (2 entries)

TitleTitleTxtAverage Hours Per WeekAverageHoursPerWeekRtAverage Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRtIndividual Trustee Or DirectorIndividualTrusteeOrDirectorIndReportable Comp From OrgReportableCompFromOrgAmtReportable Comp From Rltd OrgReportableCompFromRltdOrgAmtOther CompensationOtherCompensationAmtOfficerOfficerInd
ROBERT T ROGERSII MD
DIRECTOR1.0050.00Yes (X)$0$316,146$17,020
RICHARD D JACOBS
FINANCE8.0050.00$0$272,822$30,704Yes (X)
FieldValueIRS element (for citing)
Tot Reportable Comp Rltd Org$588,968TotReportableCompRltdOrgAmt
Total Other Compensation$47,724TotalOtherCompensationAmt
Former Ofcr Employees ListedfalseFormerOfcrEmployeesListedInd
Total Comp Greater Than150 KYes (true)TotalCompGreaterThan150KInd
Compensation From Other SrcsfalseCompensationFromOtherSrcsInd

Contractor Compensation ContractorCompensationGrp

Contractor Name ContractorName

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1ECLINICAL WORKS LLCBusinessNameLine1Txt

Contractor Address ContractorAddress

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 847950AddressLine1Txt
CityBOSTONCityNm
State AbbreviationMAStateAbbreviationCd
ZIP022847950ZIPCd
FieldValueIRS element (for citing)
ServicesELEC. MED. REC.ServicesDesc
Compensation$107,042CompensationAmt
FieldValueIRS element (for citing)
Cntrct Rcvd Greater Than100 K1CntrctRcvdGreaterThan100KCnt

Program Service Revenue ProgramServiceRevenueGrp

FieldValueIRS element (for citing)
DescPROGRAM SERVICE REVENUEDesc
Business621400BusinessCd
Total Revenue Column$3,879,270TotalRevenueColumnAmt
Related Or Exempt Func Income$3,879,270RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Total Program Service Revenue$3,879,270TotalProgramServiceRevenueAmt

Other Revenue Misc OtherRevenueMiscGrp

FieldValueIRS element (for citing)
DescOTHER OPERATING REVENUEDesc
Business621400BusinessCd
Total Revenue Column$11,796TotalRevenueColumnAmt
Related Or Exempt Func Income$11,796RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Other Revenue Total$11,796OtherRevenueTotalAmt

Total Revenue TotalRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$3,891,066TotalRevenueColumnAmt
Related Or Exempt Func Income$3,891,066RelatedOrExemptFuncIncomeAmt

Other Salaries And Wages OtherSalariesAndWagesGrp

FieldValueIRS element (for citing)
Total$4,956,548TotalAmt
Program Services$4,726,184ProgramServicesAmt
Management And General$230,364ManagementAndGeneralAmt

Other Employee Benefits OtherEmployeeBenefitsGrp

FieldValueIRS element (for citing)
Total$828,765TotalAmt
Program Services$790,247ProgramServicesAmt
Management And General$38,518ManagementAndGeneralAmt

Fees For Services Management FeesForServicesManagementGrp

FieldValueIRS element (for citing)
Total$196,177TotalAmt
Management And General$196,177ManagementAndGeneralAmt

Occupancy OccupancyGrp

FieldValueIRS element (for citing)
Total$239,741TotalAmt
Program Services$228,599ProgramServicesAmt
Management And General$11,142ManagementAndGeneralAmt

Travel TravelGrp

FieldValueIRS element (for citing)
Total$10,910TotalAmt
Program Services$10,403ProgramServicesAmt
Management And General$507ManagementAndGeneralAmt

Conferences Meetings ConferencesMeetingsGrp

FieldValueIRS element (for citing)
Total$19,282TotalAmt
Program Services$18,386ProgramServicesAmt
Management And General$896ManagementAndGeneralAmt

Interest InterestGrp

FieldValueIRS element (for citing)
Total$10TotalAmt
Program Services$10ProgramServicesAmt

Depreciation Depletion DepreciationDepletionGrp

FieldValueIRS element (for citing)
Total$147,955TotalAmt
Program Services$141,079ProgramServicesAmt
Management And General$6,876ManagementAndGeneralAmt

Insurance InsuranceGrp

FieldValueIRS element (for citing)
Total$166,146TotalAmt
Program Services$162,671ProgramServicesAmt
Management And General$3,475ManagementAndGeneralAmt

Other Expenses OtherExpensesGrp (4 entries)

DescDescTotalTotalAmtProgram ServicesProgramServicesAmtManagement And GeneralManagementAndGeneralAmt
SUPPLIES$254,465$252,309$2,156
PURCHASED SERVICES$161,379$153,879$7,500
OTHER$35,436$33,789$1,647
LICENSES AND DUES$35,251$33,613$1,638

All Other Expenses AllOtherExpensesGrp

FieldValueIRS element (for citing)
Total$1,780TotalAmt
Program Services$1,697ProgramServicesAmt
Management And General$83ManagementAndGeneralAmt

Total Functional Expenses TotalFunctionalExpensesGrp

FieldValueIRS element (for citing)
Total$7,053,845TotalAmt
Program Services$6,552,866ProgramServicesAmt
Management And General$500,979ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Cash Non Interest Bearing CashNonInterestBearingGrp

FieldValueIRS element (for citing)
BOY$131,365BOYAmt
EOY$26,110EOYAmt

Accounts Receivable AccountsReceivableGrp

FieldValueIRS element (for citing)
BOY$527,216BOYAmt
EOY$502,081EOYAmt

Inventories For Sale Or Use InventoriesForSaleOrUseGrp

FieldValueIRS element (for citing)
BOY$7,142BOYAmt
EOY$3,999EOYAmt

Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp

FieldValueIRS element (for citing)
BOY$19,103BOYAmt
EOY$22,131EOYAmt
FieldValueIRS element (for citing)
Land Bldg Equip Cost Or Other Bss$830,910LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec$370,183LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

FieldValueIRS element (for citing)
BOY$403,029BOYAmt
EOY$460,727EOYAmt

Other Assets Total OtherAssetsTotalGrp

FieldValueIRS element (for citing)
BOY$20,562BOYAmt
EOY$6,352EOYAmt

Total Assets TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$1,108,417BOYAmt
EOY$1,021,400EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

FieldValueIRS element (for citing)
BOY$27,354BOYAmt
EOY$111,347EOYAmt

Total Liabilities TotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$27,354BOYAmt
EOY$111,347EOYAmt
FieldValueIRS element (for citing)
Organization Follows SFAS117Yes (X)OrganizationFollowsSFAS117Ind

Unrestricted Net Assets UnrestrictedNetAssetsGrp

FieldValueIRS element (for citing)
BOY$1,081,063BOYAmt
EOY$910,053EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,081,063BOYAmt
EOY$910,053EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,108,417BOYAmt
EOY$1,021,400EOYAmt
FieldValueIRS element (for citing)
Info In Schedule O Part XIYes (X)InfoInScheduleOPartXIInd
Reconcilation Revenue Expnss-$3,162,779ReconcilationRevenueExpnssAmt
Other Changes In Net Assets$2,991,769OtherChangesInNetAssetsAmt
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Accountant Compile Or ReviewfalseAccountantCompileOrReviewInd
FS AuditedYes (true)FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

FieldValueIRS element (for citing)
Consolidated Basis Fincl StmtYes (X)ConsolidatedBasisFinclStmtInd
FieldValueIRS element (for citing)
Audit CommitteeYes (true)AuditCommitteeInd
Federal Grant Audit RequiredfalseFederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org509a2Yes (X)PubliclySupportedOrg509a2Ind

Gross Receipts Admissions GrossReceiptsAdmissionsGrp

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years$102,962CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$5,518,479CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$9,222,226CurrentTaxYearMinus1YearAmt
Current Tax Year$11,044,644CurrentTaxYearAmt
Total$25,888,311TotalAmt

Total509 Total509Grp

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years$102,962CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$5,518,479CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$9,222,226CurrentTaxYearMinus1YearAmt
Current Tax Year$11,044,644CurrentTaxYearAmt
Total$25,888,311TotalAmt
FieldValueIRS element (for citing)
Public Support Total509$25,888,311PublicSupportTotal509Amt

Other Income509 OtherIncome509Grp

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years$40CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$1,698CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$31CurrentTaxYearMinus1YearAmt
Current Tax Year$11,796CurrentTaxYearAmt
Total$13,565TotalAmt

Total Support Calendar Year TotalSupportCalendarYearGrp

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years$103,002CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$5,520,177CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$9,222,257CurrentTaxYearMinus1YearAmt
Current Tax Year$11,056,440CurrentTaxYearAmt
Total$25,901,876TotalAmt
FieldValueIRS element (for citing)
First5 Years509Yes (X)First5Years509Ind

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp

FieldValueIRS element (for citing)
Form And Line ReferencePART III, LINE 12FormAndLineReferenceDesc
ExplanationMISCELLANEOUS INCOME 13,565ExplanationTxt

Schedule D IRS990ScheduleD

Leasehold Improvements LeaseholdImprovementsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$18,978OtherCostOrOtherBasisAmt
Depreciation$10,728DepreciationAmt
Book Value$8,250BookValueAmt

Equipment EquipmentGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$811,932OtherCostOrOtherBasisAmt
Depreciation$359,455DepreciationAmt
Book Value$452,477BookValueAmt
FieldValueIRS element (for citing)
Total Book Value Land Buildings$460,727TotalBookValueLandBuildingsAmt
Footnote TextYes (X)FootnoteTextInd

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE D, PAGE 3, PART XFormAndLineReferenceDesc
ExplanationINCOME TAXES OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS: THE HOSPITAL AND CPMP ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM THE FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL AND CPMP RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN FIFTY PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT. CHANGES IN RECOGNITION IN MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGEMENT OCCURS. THE HOSPITAL AND CPMP DID NOT RECOGNIZE THE EFFECT OF ANY UNCERTAIN INCOME TAX POSITIONS IN EITHER 2016 OR 2015.ExplanationTxt

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance PaymentfalseSeverancePaymentInd
Supplemental Nonqual Rtr PlanfalseSupplementalNonqualRtrPlanInd
Equity Based Comp ArrngmfalseEquityBasedCompArrngmInd
Comp Based On Revenue Of Flng OrgfalseCompBasedOnRevenueOfFlngOrgInd
Comp Bsd On Rev Related OrgsfalseCompBsdOnRevRelatedOrgsInd
Comp Bsd Net Earns Flng OrgfalseCompBsdNetEarnsFlngOrgInd
Comp Bsd Net Earns Rltd OrgsfalseCompBsdNetEarnsRltdOrgsInd
Any Non Fixed PaymentsfalseAnyNonFixedPaymentsInd
Initial Contract ExceptionfalseInitialContractExceptionInd

Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)

TitleTitleTxtCompensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmtDeferred Comp Rltd OrgsDeferredCompRltdOrgsAmtNontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmtTotal Compensation Rltd OrgsTotalCompensationRltdOrgsAmt
ROBERT T ROGERSII MD
DIRECTOR$316,146$5,300$11,720$333,166
RICHARD D JACOBS
FINANCE$272,822$18,383$12,321$303,526

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE J, PART IIIFormAndLineReferenceDesc
ExplanationCANTON-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. AS SUCH, THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF CANTON-POTSDAM HOSPITAL SEEKS INPUT OF A CONSULTING FIRM WITH NATIONAL EXPERIENCE TO REVIEW COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AND THE REGULATORY COMPLIANCE ISSUES OF NON-FOR-PROFITS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE.ExplanationTxt

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (9 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
FORM 990, PAGE 2, PART III, LINE 4DCANTON-POTSDAM MEDICAL PRACTICE OPERATES OTHER OUTPATIENT CLINIC LOCATIONS INCLUDING THE FOLLOWING: ENT: LOCATED IN POTSDAM, NY, THIS CLINIC SERVED APPROXIMATELY 3,138 PATIENTS IN 2016. GASTRO: LOCATED IN MASSENA, NY, THIS CLINIC SERVED APPROXIMATELY 3,460 PATIENTS IN 2016. FAMILY PRACTICE: LOCATED IN COLTON, NY, THIS CLINIC SERVED APPROXIMATELY 2,561 PATIENTS IN 2016. CANTON GENERAL SURGERY: LOCATED IN CANTON, NY, THIS CLINIC OPENED IN JANUARY 2016 AND SERVED APPROXIMATELY 936 PATIENTS IN 2016.
FORM 990, PAGE 6, PART VI, LINE 3CANTON-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 8BCANTON-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 11BTHE 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 12CTHE 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 15ALINE 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 15BTHE 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 WILL THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL.
FORM 990, PAGE 6, PART VI, LINE 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 9TRANSFER FROM AFFILIATE (CANTON-POTSDAM HOSPITAL) 2,991,769

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (3 entries)

Address Line1USAddress/AddressLine1TxtCityUSAddress/CityNmState AbbreviationUSAddress/StateAbbreviationCdZIPUSAddress/ZIPCdEINEINPrimary ActivitiesPrimaryActivitiesTxtLegal Domicile StateLegalDomicileStateCdExempt Code SectionExemptCodeSectionTxtBusiness Name Line1DirectControllingEntityName/BusinessNameLine1TxtControlled OrganizationControlledOrganizationInd
ST LAWRENCE HEALTH SYSTEM INC
50 LEROY STREETPOTSDAMNY13676464259168SEE VIINY501C3NAfalse
CANTON-POTSDAM HOSPITAL
50 LEROY STREETPOTSDAMNY13676161012691HOSPITALNY501C3SLHSYes (true)
GOUVERNEUR HOSPITAL INC
77 WEST BARNEY STREETGOUVERNEURNY13642464249555HOSPITALNY501C3SLHSYes (true)
FieldValueIRS element (for citing)
Receipt Of Int Annts Rnts RyltsfalseReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth OrgfalseGiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth OrgfalseGiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth OrgfalseLoansOrGuaranteesFromOthOrgInd
Div Related OrganizationfalseDivRelatedOrganizationInd
Asset Sale To Other OrgfalseAssetSaleToOtherOrgInd
Asset Purchase From Other OrgfalseAssetPurchaseFromOtherOrgInd
Asset ExchangefalseAssetExchangeInd
Rental Of Facilities To Oth OrgfalseRentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth OrgYes (true)RentalOfFcltsFromOthOrgInd
Perform Of Services For Oth OrgfalsePerformOfServicesForOthOrgInd
Perform Of Services By Other OrgfalsePerformOfServicesByOtherOrgInd
Sharing Of FacilitiesfalseSharingOfFacilitiesInd
Paid Employees SharingfalsePaidEmployeesSharingInd
Reimbursement Paid To Other OrgfalseReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrgInd
Transfer To Other OrgfalseTransferToOtherOrgInd
Transfer From Other OrgfalseTransferFromOtherOrgInd

Transactions Related Org TransactionsRelatedOrgGrp (2 entries)

Transaction TypeTransactionTypeTxtInvolvedInvolvedAmtMethod Of Amount DeterminationMethodOfAmountDeterminationTxt
CANTON-POTSDAM HOSPITAL
K$5,992,491FMV
CANTON-POTSDAM HOSPITAL
K$141,850FMV

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE RFormAndLineReferenceDesc
ExplanationST. LAWRENCE HEALTH SYSTEM, INC. (SLHS) IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING CANTON-POTSDAM HOSPITAL, GOUVERNEUR HOSPITAL AND OTHER CORPORATIONS OF WHICH THE CORPORATION IS THE SOLE CORPORATE MEMBER INCLUDING THE CANTON-POTSDAM MEDICAL PRACTICE, PLLC.ExplanationTxt