2017-02-15T15:35:12-06:00 2016-09-30 351178661 Blue & Co LLC 500 N Meridian St Suite 200 Indianapolis IN 46204 990 2015-10-01 263083364 Deaconess Clinic Inc DEAC 8124503296 600 Mary Street Evansville IN 47747 Allen White MD Vice President 8124503296 2017-02-13 1 Carrie A Merrill CPA P00832283 3176334705 2017-02-10 2015 2021-01-29 14:40:06Z Allen White MD 421 Chestnut Street Evansville IN 47713 83609349 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. 15 1 827 0 25428 7888 0 0 77464622 82522900 -8920 -69564 1091771 805606 78547473 83258942 0 0 0 0 74323502 79913721 0 0 0 28239445 30178617 102562947 110092338 -24015474 -26833396 16346431 18285696 13332979 16009776 3013452 2275920 X See Sch O. 0 0 96432518 80377013 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 112 physicians, 47 midlevel providers and 483 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 631,328 patient visits from October 1, 2015 through September 2016. 1261932 2145887 THE RESEARCH INSTITUTE OF DEACONESS CLINIC ASSISTS DEACONESS CLINIC'S MORE THAN 125+ 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 27 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, diabetes, autism, chronic migraines, COPD, actinic keratosis, obese patients with cardiovascular risks, osteoarthritis and hyperlipidemia. THE NEW RESEARCH GRANTS PROVIDED TREATMENT OPPORTUNITES AND PREVENTATIVE HEALTH SERVICES FOR 287 PATIENTS. IN ALL, THE NEWLY AWARDED GRANTS THIS YEAR TOTALED $2.9 MILLION TO COVER THE COSTS [CONTINUATION FROM PAGE 2]ASSOCIATED WITH THE CONDUCT OF THE CLINICAL TRIALS WITHIN THE REGION. 322 patients were screened for clinical trial qualification throughout the year, with 227 new PATIeNTS ENROLLED oNTO CLINICAL protocals, RESULTING IN 3,467 RESEARCH RELATED PATIENT VISITS. THE RESEARCH INSTITUTE ALSO initiated RESEARCH projects ON INVESTIGATOR-INITIATED RESEARCH PROJECTs targeting on fall prevention in women with osteopenia and on HER2Neu 3+ breast cancer patients. THE INSTITUTE OVERSAW THE TRAINING OF two NEW CLINICAL INVESTIGATORS IN 2016, INCLUDING THEIR RESEARCH CERTIFICATIONS IN GOOD CLINICAL PRACTICE AND THE PROTECTION OF HUMAN SUBJECTS. 97694450 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 0 0 0 0 0 0 0 1 0 0 0 1 78 0 1 827 1 1 1 0 0 0 0 0 0 0 X 15 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 2400 4800 0 Cheryl Wathen Secretary/Treasurer 5.00 60.00 X X 0 645425 154318 Barry Phillips MD director 50.00 10.00 X 438674 10220 34428 James Porter MD Director 5.00 55.00 X 0 699759 158979 linda white director 5.00 60.00 X 0 1680271 246345 majed koleilat md Director 50.00 0.00 X 846811 0 42312 Maqbool AHMED MD director 50.00 10.00 X 1057701 0 56030 Jon C Davis MD Director 50.00 0.00 X 984352 0 36482 RM Galen MD director 50.00 0.00 X 309346 0 35104 Bradley Scheu MD Director 15.00 0.00 X 91347 245089 29482 Rachel Farmer MD director 50.00 0.00 X 240690 0 34707 steven etherton md Director 50.00 0.00 X 302894 0 40249 Youssef SIAGE md Director 50.00 0.00 X 312973 0 31419 Mia Hindi MD director 50.00 0.00 X 1482200 16800 43148 William Smith MD director 50.00 0.00 X 265996 230 22624 David Koehler Jr MD Director (10/1-10/31/15) 5.00 10.00 X 39110 25928 0 W Allen WHITE MD Non-voting Direct/ Vice Pr 50.00 0.00 X X 429231 0 127540 Julie DINGMAN Practice Director 50.00 0.00 X 175772 0 37320 Anvita Sinha MD physician 50.00 0.00 X 1050210 0 30558 Manga D Kodali physician 50.00 0.00 X 907381 0 15392 Shaukat Iftikhar physician 50.00 0.00 X 1020492 0 37672 Bruce Schneider MD physician 50.00 0.00 X 1329071 0 51327 Kalyana C Lavu physician 50.00 0.00 X 967498 0 37242 12254149 3328522 1302678 137 0 1 0 The Advisory Board Company PO BOx 79461 Baltimore MD 212790461 consulting 378520 Staff Care Inc PO Box 281923 Atlanta GA 303841923 locums 298018 clinical reference laboratory PO box 802273 kansas City KS 641802273 service 130304 weatherby Locums inc po Box 972633 Dallas TX 753972633 locums 125645 4 Net Patient Revenue 621110 80377013 80377013 Net Research Revenue 621110 2145887 2145887 82522900 306958 280843 26115 26115 26115 69564 -69564 -69564 -69564 USI Capitation 900099 441143 441143 CMS Meaningful Use 900099 312920 312920 Skin Care Products 621110 25428 25428 779491 83258942 82522900 25428 710614 7777818 7218848 558970 60350315 57552813 2797502 4661398 4366115 295283 4031038 3775686 255352 3093152 2897211 195941 437441 2901 434540 20861 20861 7837325 2082935 5754390 349241 271459 77782 8405960 7647818 758142 1135231 1092719 42512 9197590 8600401 597189 104382 79577 24805 630348 392494 237854 919759 861338 58421 1140479 852135 288344 110092338 97694450 12397888 0 95020 8607029 8902323 544735 746397 9938612 5055624 5198555 4882988 1901092 3753988 16346431 18285696 13332979 16009776 13332979 16009776 X 3013452 2275920 3013452 2275920 16346431 18285696 X -26833396 26095864 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 20861 20861 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. 4081065 1893386 2187679 5404878 3162238 2242640 452669 452669 4882988 DUE FROM RELATED ORGANIZATION 1735716 INVESTMENTS IN JOINT VENTURES 97818 INTANGIBLES 297118 457 Plan 1623336 3753988 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, 2016 AND 2015, 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 1 X X X X X X 0 1 0 0 0 0 0 0 0 Cheryl Wathen Secretary/Treasurer 0 417725 0 139468 0 88232 0 121128 0 33190 0 799743 0 75769 Barry Phillips MD director 350349 0 86233 0 2092 10220 13314 0 21114 0 473102 10220 0 0 James Porter MD Director 0 455118 0 149633 0 95008 0 131242 0 27737 0 858738 0 90140 linda white director 0 740718 0 345622 0 593931 0 234950 0 11395 0 1926616 0 578690 majed koleilat md Director 753597 0 90553 0 2661 0 18705 0 23607 0 889123 0 0 0 Maqbool AHMED MD director 887205 0 167850 0 2646 0 33007 0 23023 0 1113731 0 0 0 Jon C Davis MD Director 851598 0 117085 0 15669 0 14590 0 21892 0 1020834 0 0 0 RM Galen MD director 256620 0 50887 0 1839 0 18705 0 16399 0 344450 0 0 0 Bradley Scheu MD Director 66414 162320 20628 77919 4305 4850 1957 4403 7438 15684 100742 265176 0 0 Rachel Farmer MD director 204998 0 33652 0 2040 0 13205 0 21502 0 275397 0 0 0 steven etherton md Director 253681 0 47407 0 1806 0 18705 0 21544 0 343143 0 0 0 Youssef SIAGE md Director 236112 0 74719 0 2142 0 18705 0 12714 0 344392 0 0 0 Mia Hindi MD director 1409579 0 57558 0 15063 16800 14590 0 28558 0 1525348 16800 0 0 William Smith MD director 206683 0 44869 0 14444 230 14590 0 8034 0 288620 230 0 0 W Allen WHITE MD Non-voting Direct/ Vice Pr 316925 0 107142 0 5164 0 96895 0 30645 0 556771 0 0 0 Julie DINGMAN Practice Director 148027 0 26384 0 1361 0 21100 0 16220 0 213092 0 0 0 Anvita Sinha MD physician 882301 0 165947 0 1962 0 22945 0 7613 0 1080768 0 0 0 Manga D Kodali physician 805715 0 87664 0 14002 0 14590 0 802 0 922773 0 0 0 Shaukat Iftikhar physician 982029 0 24036 0 14427 0 14590 0 23082 0 1058164 0 0 0 Bruce Schneider MD physician 1237054 0 88975 0 3042 0 28245 0 23082 0 1380398 0 0 0 Kalyana C Lavu physician 937148 0 15792 0 14558 0 14590 0 22652 0 1004740 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 13,088 0 GARY KEEPES, MD 0 18,000 0 DAVID KOEHLER, MD 0 6,629 0 ANNE MCLAUGHLIN, MD 0 18,000 0 YOUSSEF SIAGE, MD 0 18,000 0 RUSTON STOLTZ, 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 KALYANA LAVU, MD 0 18,000 0 SEVERANCE NONQUALIFIED EQUITY-BASED (CONT.) JAMES R. PORTER, MD $ -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 $92,071. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $75,769. JAMES PORTER: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $102,593. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $90,140. LINDA WHITE: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $194,273. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $397,458. 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 11 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 26,095,864. 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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