2014-11-11T13:12:57-06:00 2013-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2013-01-01 611654232 WESTERN NEW YORK MEDICAL PRACTICE PC WEST 5859224806 1425 PORTLAND AVENUE ROCHESTER NY 14621 PAULA TINCH SVP FINANCE & CFO 5859224806 2014-11-05 1 ANGELA M FRANCO P00589741 3154463600 2013 2015-11-30 17:44:51Z ROBERT MAYO 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 8170769 0 X WWW.ROCHESTERGENERAL.ORG X 2011 NY THE ORGANIZATION WAS FORMED EXCLUSIVELY FOR THE CHARITABLE PURPOSE OF SERVING THE HEALTH CARE NEEDS OF THE RESIDENTS OF MONROE COUNTY AND SURROUNDING AREAS, AND EXISTS TO FURTHER THE CHARITABLE MISSION OF ROCHESTER GENERAL HOSPITAL. 2 0 0 2 0 0 0 0 712185 8170769 0 0 0 0 712185 8170769 0 0 0 0 867977 2505399 0 0 0 445640 7213631 1313617 9719030 -601432 -1548261 560416 9152067 1455405 11595317 -894989 -2443250 THE ORGANIZATION WAS FORMED EXCLUSIVELY FOR THE CHARITABLE PURPOSE OF SERVING THE HEALTH CARE NEEDS OF THE RESIDENTS OF MONROE COUNTY AND SURROUNDING AREAS, AND EXISTS TO FURTHER THE CHARITABLE MISSION OF ROCHESTER GENERAL HOSPITAL. 0 0 9683030 8170769 TO PROVIDE ACCESS TO PRIMARY CARE AND MEDICAL SPECIALTIES TO THE RESIDENTS OF MONROE COUNTY. 9683030 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 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 1 0 0 0 0 0 0 0 0 0 0 0 X 2 0 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X ANN SICKER 5859226715 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 HUGH THOMAS SVP & CORPORATE COUNSEL 1.00 54.00 X X 0 649042 173843 ROBERT MAYO MD CHIEF MEDICAL OFFICER 1.00 54.00 X X 0 438999 130842 PAULA TINCH SVP FINANCE & CFO 1.00 54.00 X 0 393805 117631 0 1481846 422316 0 0 1 0 0 PATIENT SERVICE REVENU 621110 8170769 8170769 8170769 8170769 8170769 0 0 X 2282527 2282527 222872 222872 4205555 4169555 36000 800 800 452450 452450 222472 222472 863473 863473 5665 5665 1918 1918 977 977 3871 3871 OTHER DIRECT EXPENSES 1117793 1117793 BAD DEBTS 336792 336792 DUES AND SUBSCRIPTIONS 1865 1865 9719030 9683030 36000 0 279172 7033036 51069 784572 4976 1302414 36557 4512 10199 32045 215000 0 560416 9152067 27628 237815 1427777 11357502 1455405 11595317 X -894989 -2443250 -894989 -2443250 560416 9152067 -1548261 0 X 0 1 X 1 0 X 36557 4512 32045 32045 DUE TO AFFILIATES 11357502 11357502 0 1 0 0 0 0 0 0 0 HUGH THOMAS SVP & CORPORATE COUNSEL 0 367419 0 234543 0 47080 0 165314 0 8529 0 822885 0 100627 ROBERT MAYO MD CHIEF MEDICAL OFFICER 0 322275 0 75644 0 41080 0 123297 0 7545 0 569841 0 0 PAULA TINCH SVP FINANCE & CFO 0 262103 0 114024 0 17678 0 113088 0 4543 0 511436 0 0 PART I, LINE 3 THE FILING ORGANIZATION'S RELATED NON-PROFIT ORGANIZATION, ROCHESTER GENERAL HEALTH SYSTEM, UTILIZES THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE CEO: A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4B RGHS MAINTAINS A SECTION 457(F) PLAN WHICH WOULD BE CONSIDERED A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2013, NO DISTRIBUTIONS WERE PAID OUT. THE FOLLOWING OFFICERS AND KEY EMPLOYEES LISTED ON FORM 990, PART VII, SECTION A WOULD BE ELIGIBLE PARTICIPANTS IN THE PLAN SINCE THEY WOULD BE ENTITLED TO A DISTRIBUTION UPON SEPARATION FROM SERVICE: HUGH THOMAS FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS A STOCK CORPORATION UNDER NEW YORK STATE LAW. THE ORGANIZATION'S SOLE PHYSICIAN SHAREHOLDER, IS AN EMPLOYEE OF ROCHESTER GENERAL HEALTH SYSTEM (RGHS), A RELATED NOT-FOR-PROFIT ORGANIZATION. THE ORGANIZATION IS CONSIDERED A CAPTIVE PC THAT IS CONTROLLED BY RGH THROUGH A SHAREHOLDER'S AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7A IN ACCORDANCE WITH THE TERMS AND REQUIREMENTS OF ITS GOVERNING DOCUMENTS (I.E. BYLAWS), THE ORGANIZATION'S DIRECTORS ARE ELECTED AT THE ANNUAL MEETING BY A MAJORITY VOTE OF THE DIRECTORS THEN IN OFFICE. THE TERM OF OFFICE OF EACH DIRECTOR SHALL BE UNTIL THE NEXT ANNUAL MEETING AND UNTIL HIS SUCCESSOR HAS BEEN DULY ELECTED OR APPOINTED AND QUALIFIED. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, A COPY OF THE FORM 990 IS PROVIDED TO, AND REVIEWED WITH, ALL MEMBERS OF THE AUDIT AND COMPLIANCE COMMITTEE. THIS REVIEW IS PERFORMED IN CONSULTATION WITH THE ORGANIZATION'S TAX ADVISORS, AND IS BASED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS AND OTHER RELEVANT INFORMATION FOR THE APPROPRIATE TIME PERIOD. FORM 990, PART VI, SECTION B, LINE 12C UPON EMPLOYMENT, ALL EMPLOYEES RECEIVE THE ETHICAL STANDARD OF CONDUCT BOOKLET FOR WHICH THEY SIGN A RECEIPT OF ACKNOWLEDGEMENT. CONFLICT OF INTEREST IS DEFINED, AS IS MANAGEMENT OF A CONFLICT OF INTEREST. EMPLOYEES ARE REQUIRED TO DISCLOSE AND SEEK RESOLUTION TO ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST BEFORE TAKING A POTENTIALLY IMPROPER ACTION AND THEREAFTER, ANNUALLY, EACH KEY EMPLOYEE AND OFFICER OF THE ORGANIZATION IS REQUIRED TO COMPLETE A CONFLICT OF INTEREST FORM, PROVIDING MANAGEMENT WITH SUFFICIENT INFORMATION ABOUT HIS/HER PERSONAL INTERESTS AND RELATIONSHIPS SO THAT MANAGEMENT CAN (1) DETERMINE WHETHER ANY ACTUAL OR PERCEIVED CONFLICT OF INTEREST EXISTS, AND (2) MONITOR WORK ASSIGNMENTS TO AVOID PLACING THE KEY EMPLOYEE OR OFFICER IN A POSITION WHERE THERE MAY BE A QUESTION AS TO HIS/HER OBJECTIVITY AS WELL AS TO AVOID ANY APPEARANCE OF IMPROPRIETY. THROUGHOUT THE YEAR, KEY EMPLOYEES AND OFFICERS OF THE ORGANIZATION ARE ALSO REQUIRED TO NOTIFY MANAGEMENT PROMPTLY IF ANY CHANGE TO THEIR DISCLOSURES OCCURS. IN ADDITION, EACH MEMBER OF THE BOARD OF DIRECTORS MUST ALSO COMPLETE A CONFLICT OF INTEREST AND DISCLOSURE FORM, WHICH MUST BE SUBMITTED TO THE GENERAL COUNSEL. BOARD MEMBERS LEAVE THE ROOM DURING DISCUSSIONS AND ABSTAIN FROM VOTING WHEN THEY HAVE A CONFLICT OF INTEREST. IN ADDITION TO THE BOARD OF DIRECTORS, THE ORGANIZATION'S MANAGERS AND DIRECTORS WHO OVERSEE ITS OPERATIONS COMPLETE A CONFLICT OF INTEREST FORM ANNUALLY AS WELL. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S OFFICER AND KEY EMPLOYEE COMPENSATION ARRANGEMENTS ARE REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE OF ROCHESTER GENERAL HEALTH SYSTEM, A RELATED NOT-FOR-PROFIT ORGANIZATION. INFORMATION REVIEWED FOR THE OFFICER/KEY EMPLOYEE INCLUDES COMPARABLE DATA FROM SIMILAR SIZE TAX EXEMPT ORGANIZATIONS IN THE WESTERN/CENTRAL NY COMMUNITY AS WELL AS COMPENSATION FOR THESE POSITIONS (AS DISCLOSED ON FORM 990) WITH OTHER ORGANIZATIONS IN THE INSURANCE INDUSTRY THAT ARE OF SIMILAR SIZE, DEMOGRAPHICS AND GEOGRAPHY. REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENT BY THE COMPENSATION COMMITTEE IS DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ADMINISTRATIVE OFFICES OF THE AFFILIATED HEALTH SYSTEM, LOCATED AT 100 KINGS HIGHWAY SOUTH, ROCHESTER, NY 14617 AND THE ADMINISTRATIVE OFFICES OF THE FILING ORGANIZATION. A NOMINAL FEE IS CHARGED IF COPIES ARE REQUESTED. FORM 990, PART IX, LINE 11G CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 2,120,512. MANAGEMENT AND GENERAL EXPENSES 36,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,156,512. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 2,049,043. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,049,043. FORM 5471 FILED ON BEHALF OF STATEMENT STATEMENT PURSUANT TO TREAS. REG. SEC. 1.6038-2(J)(3): THE FOLLOWING INFORMATION IS SUBMITTED WITH RESPECT TO WESTERN NEW YORK MEDICAL PRACTICE PC'S FORM 5471 (INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS) FILING REQUIREMENT FOR THE ENTITY BELOW: NAME OF FOREIGN CORPORATION: GREATER ROCHESTER ASSURANCE COMPANY, LTD. BEGINNING TAX YEAR OF FOREIGN CORPORATION: JANUARY 1, 2013 ENDING TAX YEAR OF FOREIGN CORPORATION: DECEMBER 31, 2013 THE FORM 5471 FILING REQUIREMENT FOR THIS FOREIGN CORPORATION FOR CATEGORIES 4 AND 5 HAVE BEEN SATISFIED BY INCLUSION IN THE FOLLOWING U.S. FILER'S TAX RETURN: NAME OF U.S. FILER: ROCHESTER GENERAL HEALTH SYSTEM ADDRESS OF U.S. FILER: 100 KINGS HIGHWAY SOUTH, ROCHESTER, NY 14617 EIN OR SSN: 22-2551509 ENDING TAX YEAR OF U.S. ENTITY: DECEMBER 31, 2013 TYPE OF RETURN FILED: 990-T IRS SERVICE CENTER WHERE RETURN FILED: OGDEN, UTAH 84201-0027 THE ROCHESTER GENERAL HOSPITAL 1425 PORTLAND AVENUE ROCHESTER NY 14621 160743134 HOSPITAL NY 501(C)(3) LINE 3 RGHS 0 ROCHESTER MENTAL HEALTH CENTER 490 EAST RIDGE ROAD ROCHESTER NY 14621 166069131 MENTAL HEALTH NY 501(C)(3) LINE 9 RGHS 0 GRHS FOUNDATION 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 223378111 R/E INV MGMT NY 501(C)(3) LINE 11B, II RGHS 0 THE ROCHESTER GENERAL HOSPITAL FOUNDATION 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222229425 FUNDRAISING NY 501(C)(3) LINE 11B, II RGHS 0 NEWARK WAYNE COMMUNITY HOSPITAL FOUNDATION DRIVING PARK AVENUE NEWARK NY 14513 222963344 FUNDRAISING NY 501(C)(3) LINE 11B, II NWCH 0 NEWARK WAYNE COMMUNITY HOSPITAL DRIVING PARK AVENUE NEWARK NY 14513 150584188 HOSPITAL NY 501(C)(3) LINE 3 RGHS 0 RGHS WORKERS' COMPENSATION TRUST 1425 PORTLAND AVENUE ROCHESTER NY 14621 166429300 SEE PART VII NY 501(C)(3) LINE 11B, II RGHS 0 CONTINUING CARE NETWORK INC (CCN) 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222963016 SUPPORT RGH NY 501(C)(3) LINE 11B, II RGHS 0 ROCHESTER GENERAL HUDSON HOUSING 2066 HUDSON AVENUE ROCHESTER NY 14617 223210351 LOW INC HOUSING NY 501(C)(3) LINE 9 RGHS 0 VIA HEALTH HOME CARE I 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 161504370 HOME HEALTH NY 501(C)(3) LINE 9 CCN 0 VIA HEALTH HOMECARE II 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 161538727 HOME HEALTH NY 501(C)(3) LINE 9 CCN 0 INDEPENDENT LIVING FOR SENIORS 2066 HUDSON AVENUE ROCHESTER NY 14617 161491059 ADULT DAY HC NY 501(C)(3) LINE 9 RGHS 0 ROCHESTER GENERAL LONG TERM CARE 1550 EMPIRE BLVD WEBSTER NY 14580 223187140 NH & REHAB NY 501(C)(3) LINE 9 RGHS 0 ROCHESTER GENERAL HEALTH SYSTEM 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222551509 SYSTEM PARENT NY 501(C)(3) LINE 11A, I N/A 0 GREATER ROCHESTER ASSURANCE COMPANY LTD GEORGE TOWN GRAND CAYMAN CJ INSURANCE CJ N/A C 0 ROCHESTER GENERAL HEALTH SYSTEM DIALYSIS INC 1425 PORTLAND AVE ROCHESTER NY 14621 383912199 DIALYSIS NY RGHS C 0 GREATER ROCHESTER INDEPENDENT PRACTICE ASSOCIATION INC 100 KINGS HIGHWAY SOUTH STE 2500 ROCHESTER NY 14617 161507171 INDEPENDENT PRACTICE ASSOCIATION NY N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 ROCHESTER GENERAL HOSPITAL O 9752053 FMV ROCHESTER GENERAL MEDICAL GROUP O 177672 FMV SCHEDULE R, PART II, COLUMN B: RELATED TAX-EXEMPT ORGANIZATION - PRIMARY ACTIVITY: RGHS WORKERS' COMPENSATION TRUST SUPPORTS THE GENESEE HOSPITAL, ROCHESTER GENERAL HOSPITAL, ROCHESTER GENERAL HOSPITAL FOUNDATION, NEWARK WAYNE COMMUNITY HOSPITAL, NEWARK COMMUNITY HOSPITAL FOUNDATION, INDEPENDENT LIVING FOR SENIORS, ROCHESTER GENERAL LONG TERM CARE, ROCHESTER GENERAL HUDSON HOUSING, GRHS FOUNDATION, BEHAVIORAL HEALTH NETWORK, AND ROCHESTER GENERAL HEALTH SYSTEM.