2016-07-14T09:30:05-05:00 2015-12-31 310800053 CLARK SCHAEFER HACKETT & CO 14 E MAIN STREET SUITE 500 SPRINGFIELD OH 45502 990 2015-01-01 450914398 FIVE RIVERS HEALTH CENTERS FIVE 9377344141 2261 PHILADELPHIA DR DAYTON OH 45406 DAVID MITTELKAMP CFO 9377344141 2016-07-07 1 DEVESH KAMAL CPA P00201226 9373992000 2016-07-07 2015 2016-09-27 15:27:22Z DAVID MITTELKAMP 2261 PHILADELPHIA DR DAYTON OH 45406 15973110 0 X WWW.FIVERIVERSHEALTHCENTERS.ORG X 2011 OH FIVE RIVER HEALTH CENTERS AIMS TO LIVE OUT OUR MISSION FOR OUR PATIENTS - "YOUR HEALTHCARE MATTERS!" 13 13 203 0 0 0 6065227 8437082 6043082 7536028 0 0 0 0 12108309 15973110 0 0 0 0 3372645 7961488 0 0 0 9170234 6746548 12542879 14708036 -434570 1265074 2461669 4025517 1549345 1848119 912324 2177398 FIVE RIVERS HEALTH CENTERS ARE COMMITTED TO PROVIDING QUALITY, COST-EFFECTIVE CARE FOR OUR PATIENTS AND COMMUNITY, WITH RESPECT AND DIGNITY, AND WITHOUT REGARD TO ABILITY TO PAY, WHILE PROVIDING A SUPERIOR EDUCATIONAL EXPERIENCE FOR RESIDENTS AND OTHER LEARNERS. 0 0 12972471 7536028 PROVIDE QUALITY, COST-EFFECTIVE CARE FOR OUR PATIENTS AND COMMUNITY WITH RESPECT AND DIGNITY, AND WITHOUT REGARD TO ABILITY TO PAY, WHILE PROVIDING A SUPERIOR EDUCATIONAL EXPERIENCE FOR RESIDENTS AND OTHER LEARNERS. IN 2015, CARE WAS PROVIDED TO APPROXIMATELY 15,000 PATIENTS. 12972471 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 46 0 1 203 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X DAVID MITTELKAMP 9377346844 2261 PHILADELPHIA DR DAYTON OH 45406 AMY WIEDEMAN PRESIDENT 1.00 X X 0 0 0 RACHEL SELBY VICE PRESIDENT 1.00 X X 0 0 0 RENEE GEORGE TREASURER 1.00 X X 0 0 0 DWIGHT BROWN SECRETARY 1.00 X X 0 0 0 DR MARGARET DUNN DIRECTOR 1.00 X 0 0 0 RONA CLARK DIRECTOR 1.00 X 0 0 0 RICHARD GOSHAY DIRECTOR 1.00 X 0 0 0 TRISCHA COATES DIRECTOR 1.00 X 0 0 0 JEFF COOPER DIRECTOR 1.00 X 0 0 0 VERA CROWE DIRECTOR 1.00 X 0 0 0 DIANE WELBORN DIRECTOR 1.00 X 0 0 0 SERENE DUDLEY DIRECTOR 1.00 X 0 0 0 NANCY SCHIFFLER DIRECTOR 1.00 X 0 0 0 DAVE BRIDGE CFO 40.00 X 93670 0 16274 GINA MCFARLANE-EL EXECUTIVE DIRECTOR 40.00 X 151306 0 19431 DIANE CUMMINS COO 40.00 X 28247 0 4345 NICOLE CRASE PHARMACY MANAGER 40.00 X 115672 0 0 MARY GORNIAK CERTIFIED NURSE MIDWIFE 40.00 X 116478 0 0 CARL CRUTCHFIELD DENTIST 40.00 X 135571 0 0 DONNA GAU-JATA CERTIFIED NURSE MIDWIFE 40.00 X 104745 0 0 KATHRYN LOWRY COLLINS CERTIFIED NURSE MIDWIFE 40.00 X 100455 0 0 846144 0 40050 6 0 1 0 WRIGHT STATE PHYSICIANS 725 UNIVERSITY BOULEVARD DAYTON OH 45435 MEDICAL SERVICES 1103000 WSU DEPT OF MEDICINE ONE WYOMING STREET DAYTON OH 45409 MEDICAL SERVICES 228188 PREMIER HEALTH SPECIALISTS INC 110 N MAIN ST DAYTON OH 45402 MEDICAL SERVICES 128750 3 2856491 5580591 222601 8437082 MEDICAID, NET 621400 6553005 6553005 PHARMACY 621400 585503 585503 MEDICARE, NET 621400 279311 279311 MISCELLANEOUS 624100 97981 97981 FIRST AND THIRD PARTIES, NET 621400 17658 17658 2570 2570 7536028 15973110 7536028 0 0 273223 273223 6270427 5723113 547314 925923 806059 119864 491915 430644 61271 12434 12434 26250 26250 108386 102248 6138 60312 12162 48150 137861 110087 27774 1297111 1249882 47229 38595 25667 12928 87657 77335 10322 7557 7557 167193 102183 65010 145532 143172 2360 CONTRACT SERVICES 2677883 2305741 372142 PHARMACY COSTS 703626 703626 MEDICAL SUPPLIES 459701 459701 MEMBERSHIP DUES 318920 237132 81788 497530 483719 13811 14708036 12972471 1735565 0 151389 686003 1049704 1274266 963745 7696 9093 428316 399401 1380894 463323 600002 917571 2461669 4025517 324458 697396 1224887 1150723 1549345 1848119 X 912324 2177398 912324 2177398 2461669 4025517 1265074 0 X X 0 1 X 1 1 1 X 4700300 6565250 8201000 6065227 8437082 33968859 996783 2066404 4299695 6043082 7536028 20941992 5697083 8631654 12500695 12108309 15973110 54910851 0 0 0 54910851 5697083 8631654 12500695 12108309 15973110 54910851 X SCHEDULE A, PART III, SECTION A THE ORGANIZATION WAS FORMED ON MAY 23, 2011 THUS CREATING A SHORT-YEAR TAX RETURN FOR 2011. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 355418 104964 250454 1025476 358359 667117 917571 ACCRUED PAYROLL AND WITHHOLDING 664885 ACCRUED LEASED PAYROLL AND BENEFITS 1710 OTHER ACCRUED LIABILITIES 89512 CAPITAL LEASE 394616 1150723 X 16974675 1001565 1001565 15973110 0 15973110 15709601 1001565 1001565 14708036 0 14708036 PART X, LINE 2: FIVE RIVERS HEALTH CENTER IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. HOWEVER, INCOME FROM CERTAIN ACTIVITIES NOT DIRECTLY RELATED TO THE CENTER'S TAX-EXEMPT PURPOSE IS SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. THE CENTER'S REPORTING RETURNS ARE SUBJECT TO AUDIT BY FEDERAL AND STATE TAXING AUTHORITIES. NO INCOME TAX PROVISION HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS AS THE CENTER HAS DETERMINED IT DOES NOT HAVE UNRELATED BUSINESS INCOME SUBJECT TO TAXATION. X X 0 0 0 0 0 0 0 0 0 GINA MCFARLANE-EL EXECUTIVE DIRECTOR 151306 0 0 0 0 0 6411 0 13020 0 170737 0 0 0 PART I, LINE 3 THE COMPENSATION COMMITTEE USES MARKET DATA TO DETERMINE SALARIES. DR MARGARET DUNN BOARD MEMBER AND CEO OF WRIGHT STATE PHYSICIANS 1103000 MEDICAL SERVICES PROVIDED BY WRIGHT STATE PHYSICIANS 0 X VACCINES 0 222601 COST OF MATERIALS 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 DR. MARGARET DUNN, A BOARD MEMBER IS THE CEO OF WRIGHT STATE PHYSICIANS, AN ORGANIZATION THAT PROVIDED MEDICAL SERIVCES DURING 2015. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE COMMITTEE WILL REVIEW THE 990 AND APPROVE THE REPORT. AFTER APPROVING THE 990, THE FINANCE COMMITTEE WILL TAKE THE 990 TO THE BOARD FOR BOARD APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C EMPLOYEES ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST. OPERATING POLICIES HAVE BEEN IMPLEMENTED TO DETECT POTENTIAL CONFLICTS OF INTEREST. CONTRACTS OR EXPENDITURES THAT ARE GREATER THAN $50,000 MUST HAVE BOARD APPROVAL. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE USES MARKET DATA TO DETERMINE SALARIES. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATIONS 990 IS AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: THE FINANCE COMMITTEE FOR THE ORGANIZATION SELECTS AN INDEPENDENT ACCOUNTING FIRM TO CONDUCT THE AUDIT OF THE FINANCIAL STATEMENTS AND PROVIDES OVERSIGHT FOR THE WORK THAT IS CONDUCTED. THIS REPRESENTS NO CHANGE IN THE PROCESS FROM PROCEDURES CONDUCTED IN PRIOR PERIODS.