2013-05-10T08:16:33-05:00 2012-06-30 861065772 DELOITTE TAX LLP 250 EAST FIFTH STREET SUITE 1900 CINCINNATI OH 45202 990 2011-07-01 311459815 CHMC COMMUNITY HEALTH SERVICES NETWORK CHMC 5136368778 3333 BURNET AVENUE CINCINNATI OH 452293039 SCOTT J HAMLIN 5136368778 2013-05-09 1 JAMES SOWAR P00529407 5137847100 2011 2016-02-24 21:20:13Z DEE ELLINGWOOD 3333 BURNET AVENUE CINCINNATI OH 452293039 3090472 0 X N/A X 1995 OH PROVIDE MEDICAL SERVICES TO CHILDREN IN THE COMMUNITY 5 0 0 0 0 0 0 0 2871766 2862546 0 0 63565 227926 2935331 3090472 0 0 0 0 1821704 1869617 0 0 0 847154 839115 2668858 2708732 266473 381740 942086 1348998 0 25172 942086 1323826 X CHMC COMMUNITY HEALTH SERVICES NETWORK ("CHSN") IS ORGANIZED AND OPERATED EXCLUSIVELY TO SUPPORT CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC") IN CCHMC'S EFFORTS TO PROVIDE MEDICAL SERVICES TO ALL OF THE CHILDREN IN THE COMMUNITY. 0 0 2708732 3090472 CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC") IS DEVOTED TO PROVIDING MEDICAL SERVICES TO ALL OF THE CHILDREN IN THE COMMUNITY. CHMC COMMUNITY HEALTH SERVICES NETWORK ("CHSN") IS ORGANIZED AND OPERATED EXCLUSIVELY TO SUPPORT CHMC IN THIS EFFORT BY REACHING OUT TO THE MEDICALLY UNDERSERVED AND ECONOMICALLY DISADVANTAGED NEIGHBORHOODS OF OUR COMMUNITY.CHSN SERVES AS THE STRUCTURE FOR BRINGING MEDICAL PROFESSIONALS WHO SHARE THE VISION OF PROVIDING QUALITY MEDICAL CARE TO THE UNDERPRIVILEGED AND UNDERSERVED. CHSN CARRIES OUT ITS CHARITABLE PURPOSES BY SEEKING AND HIRING SUCH "MISSION" ORIENTED PHYSICIANS. IN ADDITION, CHSN WILL MAKE MEDICAL PROFESSIONALS AN INTEGRAL PART OF THESE UNDERPRIVILEGED NEIGHBORHOODS BY ESTABLISHING SITES WITHIN THESE COMMUNITIES WHERE RESIDENT PHYSICIANS WILL WORK. THE RESIDENT PHYSICIANS WILL BE ABLE TO LEARN MORE ABOUT THE PATIENTS THEY SEEK TO SERVE AND THEREBY PROVIDE BETTER SERVICE TO THEM. FURTHERMORE, IN ORDER TO ENSURE ITS GOALS ARE MET, CHSN WILL ACT AS A LIASON BETWEEN THE NEIGHBORHOODS AND CCHMC AND WILL FOCUS ON HOW TO BEST MEET THE DIFFICULT AND UNIQUE NEEDS OF THE UNDERPRIVILEGED NEIGHBORHOODS OF OUR COMMUNITY. 2708732 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 0 1 1 0 X MICHAEL BAUER 5136368778 3333 BURNET AVENUE CINCINNATI OH 452293039 MICHAEL FISHER 1.00 X 0 831532 303809 DEE ELLINGWOOD 1.00 X X 0 537364 98772 SCOTT J HAMLIN 1.00 X X 0 821244 167463 STEVE MUETHING MD 1.00 X 0 282629 44124 TOM DEWITT MD 1.00 X 0 296515 44259 0 2769284 658427 0 0 1 0 0 NET PATIENT REVENUES 621990 2862546 2862546 2862546 227926 227926 227926 3090472 3090472 0 0 1606984 1606984 262633 262633 13207 13207 258064 258064 92282 92282 11516 11516 2646 2646 COLLECTION FEES 329462 329462 PURCHASED SERVICES 52579 52579 DUES 34628 34628 TELEPHONE 24449 24449 20282 20282 2708732 2708732 0 0 454223 163489 198583 173447 114601 105239 12008 9362 277272 1002700 942086 1348998 0 25172 0 25172 X 942086 1323826 942086 1323826 942086 1348998 381740 0 X 0 1 1 X 0 X 2958758 2455249 2702574 2871766 2862546 13850893 2958758 2455249 2702574 2871766 2862546 13850893 0 0 0 13850893 92872 56312 64829 63565 227926 505504 3051630 2511561 2767403 2935331 3090472 14356397 0.96480 0.97480 0.00000 X 114601 105239 9362 9362 RECEIVABLE FROM CCHMC 1002700 1002700 0 1 0 0 0 0 0 0 0 MICHAEL FISHER 0 692284 0 100000 0 39248 0 275827 0 27982 0 1135341 0 0 DEE ELLINGWOOD 0 354812 0 118882 0 63670 0 72392 0 26380 0 636136 0 23888 SCOTT J HAMLIN 0 586671 0 176007 0 58566 0 142602 0 24861 0 988707 0 19319 STEVE MUETHING MD 0 233632 0 26561 0 22436 0 24500 0 19624 0 326753 0 0 TOM DEWITT MD 0 264003 0 0 0 32512 0 24500 0 19759 0 340774 0 0 PART I, LINE 4B CERTAIN OFFICERS AND KEY EMPLOYEES OF CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"), A RELATED ORGANIZATION TO CHSN, HAVE ARRANGEMENTS WHICH PROVIDE FOR SUPPLEMENTAL RETIREMENT BENEFITS AS DESCRIBED IN IRC SEC. 457(F). DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THESE ARRANGEMENTS ARE NON-VESTED AND THERE IS NO GUARANTEE THAT THESE OFFICERS AND FACULTY MEMBERS WILL EVER RECEIVE THESE BENEFITS. THE FOLLOWING IS A LISTING OF OFFICERS AND KEY EMPLOYEES THAT RECEIVED A DEFERRAL, SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, UNDER CCHMC'S IRC SEC. 457(F) PLAN DURING THE YEAR (THESE AMOUNTS ARE INCLUDED IN THE TOTALS FOR SCHEDULE J, PART II, COLUMN C, DEFERRED COMPENSATION): 1. DEE ELLINGWOOD - $47,892 2. SCOTT HAMLIN - $118,102 3. MICHAEL FISHER - $251,327 THE FOLLOWING IS A LISTING OF OFFICERS AND KEY EMPLOYEES THAT RECEIVED A PAYMENT UNDER CCHMC'S IRC SEC. 457(F) PLAN DURING THE YEAR: 1. DEE ELLINGWOOD - $23,888 2. SCOTT HAMLIN - $19,319 SUPPLEMENTAL INFORMATION PART III CHMC COMMUNITY HEALTH SERVICES NETWORK RELIED ON CHILDREN'S HOSPITAL MEDICAL CENTER ("CHMC"), A RELATED ORGANIZATION, TO ESTABLISH THE COMPENSATION OF INDIVIDUALS LISTED ON FORM 990, PART VII. CHMC USED ONE OR MORE OF THE METHODS DESCRIBED BELOW TO ESTABLISH AN APPROPRIATE LEVEL OF COMPENSATION: COMPENSATION COMMITTEE INDEPENDENT COMPENSATION CONSULTANT FORM 990 OF OTHER ORGANIZATIONS COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE EXPLANATION OF BENEFITS: ALL COMPENSATION AND BENEFITS REPORTED ON FORM 990, PART VII AND SCHEDULE J, PART II ARE PROVIDED BY CHMC, A RELATED ENTITY TO CHSN. THE EMPLOYEE BENEFIT PLAN CONTRIBUTION AMOUNTS LISTED ON SCHEDULE J, PART II MAY INCLUDE ONE OR MORE OF THE FOLLOWING BENEFITS: 1. ELECTIVE EMPLOYEE DEFERRALS UNDER IRC SEC. 403(B) 2. DISCRETIONARY EMPLOYER CONTRIBUTIONS UNDER IRC SEC. 403(B) 3. ELECTIVE EMPLOYEE DEFERRALS UNDER IRC SEC. 457(B) 4. ELECTIVE EMPLOYEE DEFERRALS UNDER IRC SEC. 457(F) IN ADDITION TO THE RETIREMENT PLAN CONTRIBUTIONS DISCLOSED ON FORM 990, PART VII AND SCHEDULE J, PART II, THE FOLLOWING NON-TAXABLE EMPLOYEE WELFARE BENEFITS WERE MADE AVAILABLE TO THE EMPLOYED, COMPENSATED OFFICERS AND KEY EMPLOYEES LISTED ON FORM 990, PART VII AND SCHEDULE J, PART II: 1. HEALTH AND DENTAL INSURANCE BENEFITS 2. GROUP LIFE INSURANCE (PORTIONS OF WHICH ARE TAXED) 3. UNEMPLOYMENT BENEFITS 4. DISABILITY BENEFITS THE OFFICERS AND KEY EMPLOYEES LISTED ON FORM 990, PART VII AND SCHEDULE J, PART II ARE ALSO ELIGIBLE FOR ANY OTHER AVAILABLE EMPLOYEE BENEFITS. FORM 990, PART VI, SECTION A, LINE 6 ARTICLE III OF CHSN'S CODE OF REGULATIONS PROVIDES THAT CHILDREN'S HOSPITAL MEDICAL CENTER, A RELATED ORGANIZATION, POSSESSES THE AUTHORITY TO APPOINT, ELECT, AND REMOVE MEMBERS OF CHSN'S BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A ARTICLE III OF CHSN'S CODE OF REGULATIONS PROVIDES THAT CHILDREN'S HOSPITAL MEDICAL CENTER, A RELATED ORGANIZATION, POSSESSES THE AUTHORITY TO APPOINT, ELECT, AND REMOVE MEMBERS OF CHSN'S BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11 THE CHMC COMMUNITY HEALTH SERVICES NETWORK ("CHSN") FORM 990 IS PREPARED BY SENIOR MANAGEMENT FROM CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"), A RELATED ORGANIZATION. EXTERNAL TAX CONSULTANTS THEN REVIEW THE FORM 990 FOR COMPLETENESS AND ACCURACY. THE FORM 990 IS THEN MADE AVAILABLE TO ALL CHSN BOARD MEMBERS IN ADVANCE OF FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL OF CHSN'S BOARD MEMBERS RECEIVE AN ANNUAL QUESTIONNAIRE REQUESTING INFORMATION REGARDING FAMILY AND BUSINESS RELATIONSHIPS THAT COULD POTENTIALLY RESULT IN A CONFLICT OF INTEREST UNDER CHSN'S CONFLICT OF INTEREST POLICY. ONCE THE QUESTIONNAIRES HAVE BEEN COMPLETED BY ALL OF CHSN'S BOARD MEMBERS, THE QUESTIONNAIRES ARE REVIEWED AND IF CHSN DETERMINES THAT A RELATIONSHIP EXISTS THAT PRESENTS A CONFLICT OF INTEREST, CHSN FOLLOWS THE PROVISIONS SET FORTH IN CHSN'S CONFLICT OF INTEREST POLICY TO RESOLVE THE CONFLICT AND DETERMINES THE APPROPRIATE REPORTING TO THE BOARD AND, IF REQUIRED, FORM 990 DISCLOSURE. FORM 990, PART VI, SECTION B, LINE 15 CHSN'S BOARD MEMBERS ARE EMPLOYED BY CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"), A RELATED ORGANIZATION. CCHMC HAS A COMPENSATION COMMITTEE THAT ANNUALLY REVIEWS THE RECOMMENDATIONS OF CCHMC MANAGEMENT REGARDING EMPLOYEE PERFORMANCE EVALUATION AND COMPENSATION ADJUSTMENTS FOR DISQUALIFIED PERSONS TO ENSURE THAT CCHMC HAS COMPLIED WITH THE PROVISIONS OF THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER IRC SEC. 4958. FORM 990, PART VI, SECTION C, LINE 19 CHSN'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MAINTAINED ON FILE BY CCHMC SENIOR MANAGEMENT AND ARE AVAILABLE TO THE PUBLIC UPON REQUEST EITHER IN-PERSON, BY TELEPHONE, OR BY WRITTEN REQUEST. WRITTEN WHISTLEBLOWER POLICY FORM 990, PART VI, SECTION B, QUESTION 13 CHSN'S BOARD OF TRUSTEES HAS NOT FORMALLY ADOPTED A WRITTEN WHISTLEBLOWER POLICY. HOWEVER, CHSN IS A RELATED ORGANIZATION OF CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"). CCHMC HAS A WRITTEN WHISTLEBLOWER POLICY AND CHSN ABIDES BY THE PROVISIONS OF THIS POLICY. WRITTEN DOCUMENT RETENTION & DESTRUCTION POLICY FORM 990, PART VI, SECTION B, QUESTION 14 CHSN'S BOARD OF TRUSTEES HAS NOT FORMALLY ADOPTED A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY. HOWEVER, CHSN IS A RELATED ORGANIZATION OF CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"). CCHMC HAS A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY AND CHSN ABIDES BY THE PROVISIONS OF THIS POLICY. NUMBER OF HOURS WORKED FORM 990, PART VII ALL INDIVIDUALS LISTED ON FORM 990, PART VII ARE EMPLOYED BY CHILDREN'S HOSPITAL MEDICAL CENTER ("CCHMC"), A RELATED ORAGNIZATION. EACH INDIVIDUAL DEVOTES AN AVERAGE OF 40 HOURS/WEEK FOR THEIR DUTIES TO CCHMC AND AFFILATED ENTITIES. AUDITED FINANCIAL STATEMENTS FORM 990, PART IX, LINE 2B CHSN'S FINANCIAL STATEMENTS ARE INCLUDED AS PART OF THE CHILDREN'S HOSPITAL MEDICAL CENTER & AFFILIATES FINANCIAL STATEMENT AUDIT. TRANSACTIONS WITH RELATED ORGANIZATIONS FORM 990, SCHEDULE R DURING THE TIME PERIOD COVERED BY THIS RETURN, CHMC COMMUNITY HEALTH SERVICES NETWORK RECEIVED CERTAIN ACCOUNTING AND ADMINISTRATIVE SERVICES FROM CHILDREN'S HOSPITAL MEDICAL CENTER AT NO COST. THE VALUE OF THESE SERVICES IS AN UNSPECIFIED AMOUNT. CHILDREN'S HOSPITAL MEDICAL CENTER 3333 BURNET AVE CINCINNATI OH 45229 310833936 PEDIATRIC HEALTHCARE OH 501(C)(3) 3 TCH 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 CHILDREN'S HOSPITAL MEDICAL CENTER Q 383890 CASH CHILDREN'S HOSPITAL MEDICAL CENTER R 4641398 CASH