2012-08-13T16:04:55-05:00 2011-09-30 ERNST & YOUNG US LLP 1401 MCKINNEY SUITE 1200 HOUSTON TX 77010 990 2010-10-01 760460242 TCH PEDIATRIC ASSOCIATES INC TCHP 8328242982 PO BOX 300630 HOUSTON TX 772300630 BENJAMIN MELSON 8328242982 2012-08-13 0 ERNST YOUNG US LLP 7137501500 2010 2016-02-24 21:20:13Z TEXAS CHILDRENS PEDIATRIC ASSOCIATES BENJAMIN MELSON PO BOX 300630 HOUSTON TX 772300630 151316801 0 X WWW.TEXASCHILDRENSPEDIATRICS.ORG X 1994 TX TCH PEDIATRIC ASSOCIATES, INC. PROVIDES THE FINEST PEDIATRIC CARE BY PHYSICIANS AND STAFF WHO ARE DEDICATED TO DELIVERING COMPREHENSIVE QUALITY PRIMARY CARE AND EDUCATION TO THE CHILDREN OF THE COMMUNITY. 7 4 1221 0 0 0 66891 6118174 143485398 145198113 -1515 -7380 1305394 397 144856168 151309304 0 0 0 0 95307951 96899000 0 0 0 48030069 50947895 143338020 147846895 1518148 3462409 38457258 48134854 23114011 28395542 15343247 19739312 X SEE SCHEDULE O 0 0 133038776 137632298 PATIENT CARE: PROVIDING A CONCENTRATION OF SKILLS AND RESOURCES NECESSARY TO THE DIAGNOSIS AND TREATMENT OF THE ILL CHILD FROM THE PERIOD OF BIRTH THROUGH ADOLESCENCE. TOTAL PATIENT ENCOUNTERS FOR THE YEAR ENDED 9/30/2011 WERE 1,043,710. 4201225 4539489 MEDICAL EDUCATION: CONDUCTING PARENT AND PUBLIC EDUCATION PROGRAMSNECESSARY TO PROMOTE THE PREVENTION OF ILLNESS IN CHILDREN AND TOENCOURAGE THE EARLY RECOGNITION OF THE NEED FOR HEALTH SERVICES. 2800816 3026326 MEDICAL RESEARCH: INCLUDES OUTCOMES OF STUDIES FOR PEDIATRICIMMUNIZATION. MEDICAL STAFF HAVE PUBLISHED ARTICLES INPROFESSIONAL PUBLICATIONS AS WELL AS HAVE BEEN ACTIVELY INVOLVEDIN COMMUNITY MEDICAL EDUCATION. 140040817 1 1 0 1 0 0 0 0 0 1 0 0 0 1 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 1 0 0 0 1 108 0 1 1221 1 0 0 0 0 0 0 0 0 0 0 X 7 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 X RACHEL SHUPE 8328242951 1919 S BRAESWOOD BLVD HOUSTON TX 77030 X JAMES E ALLISON III MD 31.90 X 215420 0 30830 JAN E DRUTZ MD 1.00 X 0 1900 0 MARK W KLINE MD 1.00 X X 0 1000 0 MARTIN I LORIN MD 1.00 X X 0 0 0 JOAN E SHOOK MD 1.00 X 0 1739 0 ELIZABETH SMITH MD 37.40 X 338447 0 46299 STANLEY W SPINNER MD 32.30 X 237982 0 35869 KAY TITTLE 40.00 X 0 384783 131091 PATRICIA COLEMAN 40.00 X 159856 0 28425 MELISSA FISCHER 40.00 X 190727 0 58782 THERESA LEBLANC 40.00 X 184258 0 42986 HUBERT HO 40.00 X 641057 0 39598 RAZAALI RAZAK 40.00 X 611106 0 39752 MARIA ROSSELL 40.00 X 661436 0 15724 RICHARD THALLER 28.00 X 628740 0 29811 RICHARD VADALA 40.00 X 578380 0 23095 MARKETTEA BENEKE 0.00 X 0 255939 10142 4447409 645361 532404 180 1 1 0 ETACTICS INC 4835 DARROW RD STOW OH 44224 EPIC BILLING STMTS 226709 US SECURITY ASSOCIATES INC 6009 RICHMOND 100 HOUSTON TX 77057 SECURITY SERVICES 127370 VOTER CONSUMER RESEARCH INC 325 SAWDUST THE WOODLANDS TX 77380 MARKET RESEARCH 118686 RJ AUSTIN CONSULTING DEV & TRAIN LLC 11918 DUANE STREET HOUSTON TX 77047 CONSULTING SERVICES 115000 4 6118174 6118174 OP - REVENUE 621400 144310639 144310639 NON-PATIENT OPERATING 900099 861113 861113 CLEAN CLAIMS INTEREST 900099 26361 26361 145198113 117 117 7497 -7497 -7497 -7497 MISCELLANEOUS 900099 397 0 397 397 151309304 145198113 0 -6983 2586930 2586930 78638019 77890534 747485 2484374 2386810 97564 8996164 8268687 727477 4193513 4028830 164683 2000000 2000000 3510 3510 1241982 1194870 47112 205675 201537 4138 3472455 3360810 111645 24533 16634 7899 7980265 7917574 62691 130815 126019 4796 160471 154169 6302 3487174 3350396 136778 941114 941114 MEDICAL SUPPLIES 27870870 27803752 67118 BAD DEBT 2052748 2052748 AFTER HOURS CALL CENTER 1014476 1014476 FEES AND LICENSES 163358 156943 6415 RECORDS STORAGE 112518 112518 85931 85931 147846895 140040817 7806078 0 -48776 -263360 16520000 19315000 100000 100000 5537478 5976675 3343411 3258747 358369 451603 33560804 15079393 12440560 18481411 653452 206216 161326 38457258 48134854 17245364 18658191 1921932 1509448 3946715 8227903 23114011 28395542 X 15343247 19739312 15343247 19739312 38457258 48134854 X 3462409 933656 X 0 1 1 X 0 X X X X 0 0 0 TEXAS CHILDREN'S HOSPITAL 741100555 HOSPITAL 1 1 1 140040817 1 140040817 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3510 3510 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: TEXAS CHILDREN'S HOSPITAL (TCH) MAINTAINS A GOVERNMENT RELATIONS DEPARTMENT THAT ADVOCATES FOR PUBLIC POLICY AT THE LOCAL, STATE, AND FEDERAL LEVEL. TCH SUPPORTS POLICIES THAT KEEP CHILDREN HEALTHY, BUILD A HIGH QUALITY PEDIATRIC HEALTH CARE SYSTEM, AND ADVOCATE FOR HEALTH COVERAGE FOR CHILDREN. IN ADDITION TO ADVOCACY, THE GOVERNMENT RELATIONS DEPARTMENT PROVIDES EDUCATION ON THE UNIQUE NEEDS OF PEDIATRIC HEALTH CARE PROVIDERS. TCH MAY INCUR COSTS ALLOCABLE TO TEXAS CHILDREN'S PEDIATRIC ASSOCIATES. 15207 15207 0 18952598 8787014 10165584 10450380 6277172 4173208 4142619 4142619 18481411 DUE TO HOSPL 8061228 TCH MANAGEMENT FEE PA 166675 8227903 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THERE ARE NO MATERIAL UNRECORDED TAX LIABILITIES AS OF SEPTEMBER 30, 2011. X X X X 1 1 0 1 1 1 1 0 0 JAMES E ALLISON III MD 163107 0 34558 0 17755 0 17921 0 12909 0 246250 0 0 0 ELIZABETH SMITH MD 314655 0 21970 0 1822 0 29320 0 16979 0 384746 0 0 0 STANLEY W SPINNER MD 219078 0 17614 0 1290 0 23879 0 11990 0 273851 0 0 0 KAY TITTLE 0 281711 0 81250 0 21822 0 115487 0 15604 0 515874 0 20570 PATRICIA COLEMAN 135644 0 15692 0 8520 0 19415 0 9010 0 188281 0 0 0 MELISSA FISCHER 157591 0 15447 0 17689 0 45588 0 13194 0 249509 0 0 0 THERESA LEBLANC 156941 0 21480 0 5837 0 26090 0 16896 0 227244 0 0 0 HUBERT HO 416362 0 206492 0 18203 0 23477 0 16121 0 680655 0 0 0 RAZAALI RAZAK 319674 0 274963 0 16469 0 23719 0 16033 0 650858 0 0 0 MARIA ROSSELL 534793 0 124597 0 2046 0 8558 0 7166 0 677160 0 0 0 RICHARD THALLER 200458 0 409256 0 19026 0 23057 0 6754 0 658551 0 0 0 RICHARD VADALA 375541 0 183246 0 19593 0 11815 0 11280 0 601475 0 0 0 MARKETTEA BENEKE 0 182773 0 19850 0 53316 0 1662 0 8480 0 266081 0 0 SUPPLEMENTAL INFORMATION PART III SUPPLEMENTAL COMPENSATION INFORMATION SCHEDULE J, PART I, LINE 4A SEVERANCE PAYMENT MARKETTEA BENEKE 84,052 SCHEDULE J, PART I, LINE 4B PAID/DEFERRED KAY TITTLE 101,820/90,605 MARKETTEA BENEKE 63,065/0 MELISSA FISCHER 0/21,524 DIRECTOR INCENTIVE PLAN: PAID/DEFERRED ELIZABETH SMITH 21,970/21,970 PATRICIA COLEMAN 15,692/6,753 MELISSA FISCHER 15,447/7,970 THERESA LEBLANC 21,470/11,026 457(F) THE 457(F) PLAN IS A DEFERRED COMPENSATION PLAN THAT ALLOWS ELIGIBLE EXECUTIVES, FROM THE ASSISTANT VICE PRESIDENT LEVEL TO CHIEF EXECUTIVE OFFICER, TO CONTRIBUTE MONEY ON A PRE-TAX BASIS. FUNDS MAY BE DEFERRED INTO THIS ACCOUNT FROM ANY OF FOUR SOURCES: BASE SALARY, ANNUAL INCENTIVE PLAN, LONG-TERM INCENTIVE PLAN, AND CAPITAL ACCUMULATION ACCOUNT FROM A FLEXIBLE BENEFIT ACCOUNT SURPLUS. THESE VEST AFTER THREE YEARS IN THE 457(F) WITH THE EXCEPTION OF THE CAPITAL ACCUMULATION ACCOUNT WHICH VESTS AFTER FIVE YEARS IN THE 457(F) PLAN. SEVERANCE SEVERANCE IS DETERMINED ON A CASE-BY-CASE BASIS, WITH LEGAL COUNSEL INVOLVED IN THE DECISION. CONSIDERATION IS GIVEN TO FACTORS SUCH AS LENGTH OF SERVICE AND LEVEL OF POSITION WITH THE ORGANIZATION. DIRECTOR INCENTIVE PLAN THE DIRECTOR INCENTIVE PLAN IS AN ANNUAL INCENTIVE PLAN IN WHICH ELIGIBLE DIRECTORS PARTICIPATE. THE PLAN SHARES GOALS WITH THE EXECUTIVE ANNUAL INCENTIVE PLAN, FOCUSING ON FACTORS SUCH AS FINANCIAL PERFORMANCE, QUALITY GOALS, AND PATIENT SATISFACTION. IN ADDITION, THERE ARE INDIVIDUAL COMPONENTS FOR EACH DIRECTOR WHICH VARY DEPENDING ON THE EXPECTED OUTCOMES FOR THAT AREA AND/OR YEAR. SCHEDULE J, PART 5A, 5B, 6A, 6B FY 2010 EXECUTIVE ANNUAL INCENTIVE PLAN: THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES (THE "COMMITTEE") ESTABLISHES THE PERFORMANCE MEASURES FOR THE ONE-YEAR PLAN AND THE INCENTIVE AWARD OPPORTUNITY FOR EACH PARTICIPANT IN THIS PLAN. PERFORMANCE MEASURES AND GOALS ARE DEFINED FOR EACH ENTITY. THE INCENTIVE AWARDS ARE DETERMINED ON THE WEIGHTED BLEND OF ALL THE ENTITIES' PERFORMANCE. THE PERFORMANCE MEASURES INCLUDE THE FOLLOWING INDICATORS: STRATEGIC, OPERATIONAL, FINANCIAL, PATIENT SATISFACTION, CLINICAL AND SERVICE QUALITY, AND HUMAN RESOURCES. THE PERFORMANCE MEASURES ESTABLISHED BY THE COMMITTEE USE REVENUE AS A FACTOR IN DETERMINING SOME MEASURES FOR THE FINANCIAL TARGETS. THE PAYMENT OF ANNUAL INCENTIVES IS CONTINGENT ON ACHIEVING SYSTEM BUDGETED OPERATING MARGIN. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE MEMBER, TEXAS CHILDREN'S HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER ANNUALLY APPOINTS THE ORGANIZATION'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B PER THE ORGANIZATION'S BYLAWS THE MEMBER HAS CERTAIN RESERVED POWERS: ~ APPROVE, INTERPRET OR CHANGE THE PURPOSE OF THE CORPORATION. ~ FIX THE NUMBER, APPOINT OR REMOVE, WITH OR WITHOUT CAUSE, ANY DIRECTOR OF THE CORPORATION. ~ APPROVE THE MERGER, DISSOLUTION OR CONSOLIDATION OR REORGANIZATION OF THE CORPORATION. ~ APPROVE THE ACQUISITION, SALE, LEASE, TRANSFER, OR OTHER ALIENATION OF PROPERTY OF THE CORPORATION, OTHER THAN IN THE USUAL AND REGULAR COURSE OF THE CORPORATION'S BUSINESS, WHEN SUCH ACQUISITION, SALE, LEASE, TRANSFER OR OTHER ALIENATION IS ABOVE SPECIFIC FINANCIAL LEVELS SET IN ACCORDANCE WITH POLICIES ESTABLISHED FROM TIME TO TIME BY THE MEMBER. ~ APPROVE CAPITAL AND OPERATING BUDGETS OF THE CORPORATION. ~ APPROVE DEBT INCURRED BY THE CORPORATION, WHICH IS IN EXCESS OF SUCH LIMITS AS ARE ESTABLISHED BY THE MEMBER. ~ APPROVE THE DISPOSITION OF ASSETS OF THE CORPORATION AT THE TIME OF ITS DISSOLUTION. ~ APPROVE ANY LONG-RANGE FINANCIAL OR STRATEGIC PLANS FOR THE CORPORATION. ~ TAKE ANY ACTION WHICH WOULD BE INCONSISTENT WITH THE GOVERNING DOCUMENTS OR POLICIES OF THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 PER A RESOLUTION APPROVED BY THE MEMBER'S BOARD OF DIRECTORS, THE MEMBER BOARD'S AUDIT & COMPLIANCE COMMITTEE HAS THE DELEGATED AUTHORITY TO REVIEW THE ORGANIZATION'S COMPLETED FORM 990 PRIOR TO FILING. FOLLOWING THE COMMITTEE'S REVIEW, THE COMPLETED FORM 990 IS DISTRIBUTED TO THE MEMBERS OF THE ORGANIZATION'S BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION CONSISTENTLY MONITORS AND ENFORCES THE CONFLICT OF INTEREST POLICY THROUGH TWO SEPARATE PROCESSES, ONE THAT APPLIES TO THE BOARD MEMBERS, AND A SECOND THAT APPLIES TO OFFICERS AND KEY EMPLOYEES. 1)BOARD MEMBERS: PER THE ORGANIZATION'S BOARD-APPROVED CONFLICTS REVIEW PROCESS, RESPONSES TO THE ANNUAL CONFLICTS QUESTIONNAIRE ARE REVIEWED BY THE MEMBER'S BOARD LEADERSHIP AND PRESENTED TO THE MEMBER'S AUDIT & COMPLIANCE COMMITTEE. IF THE COMMITTEE DEEMS THERE ARE ANY SIGNIFICANT ISSUES, THE RESPONSES ARE THEN REVIEWED BY THE MEMBER BOARD'S EXECUTIVE COMMITTEE AND ANY REQUIRED ACTION (RECUSEMENT FROM BOARD DELIBERATIONS RELATED TO THE CONFLICT, ETC.) IS TAKEN IN ACCORDANCE WITH THE ORGANIZATION'S BOARD-APPROVED CODE OF CONDUCT. 2)OFFICERS / KEY EMPLOYEES: PER THE ORGANIZATION'S BOARD-APPROVED CONFLICTS REVIEW PROCESS, RESPONSES TO THE ANNUAL CONFLICTS QUESTIONNAIRE ARE REVIEWED BY THE COMPLIANCE SERVICES DEPARTMENT. IF THE DEPARTMENT DEEMS THERE ARE ANY SIGNIFICANT ISSUES, REQUIRED ACTION IS TAKEN IN ACCORDANCE WITH THE ORGANIZATION'S BOARD-APPROVED CODE OF CONDUCT AND THE BOARD IS NOTIFIED OF SUCH ACTIONS. FORM 990, PART VI, SECTION B, LINE 15B THE PROCESS FOR DETERMINING COMPENSATION INCLUDES: -REVIEW AND APPROVAL BY GOVERNING BODY AND COMPENSATION COMMITTEE, PROVIDED THAT PERSONS WITH A CONFLICT OF INTEREST WITH RESPECT TO THE COMPENSATION ARRANGEMENT AT ISSUE WERE NOT INVOLVED. -COMPARABLE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. -CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION AGREEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. TITLES OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES PART VII MARK W KLINE MD - BOARD MEMBER/CHAIRMAIN/CHIEF MEDICAL OFFICER (2010 - 2011) MARTIN I LORIN MD - BOARD MEMBER/VICE CHAIRMAN/SECRETARY (2010 - 2011) KAY TITTLE'S 40 HOURS AVERAGE PER WEEK REPRESENTS HER ROLE AS TEXAS CHIDREN'S PEDIACTRIC ASSOCIATES INC PRESIDENT IN CONJUNCTION WITH HER ROLE AS SENIOR VICE PRESIDENT FOR TEXAS CHILDREN'S HOSPITAL. JAMES E ALLISON III, MD 31.90 HOURS AVERAGE PER WEEK REPRESENTS HIS ROLE AS TEXAS CHILDREN'S PEDIACTRIC ASSOCIATES BOARD MEMBER (1 HOUR AVERAGE PER WEEK) AS WELL AS HIS ROLE AS A COMPENSATED PHYSICIAN. ELIZABETH SMITH, MD 37.40 HOURS AVERAGE PER WEEK REPRESENTS HER ROLE AS TEXAS CHILDREN'S PEDIACTRIC ASSOCIATES BOARD MEMBER (1 HOUR AVERAGE PER WEEK)AS WELL AS HER ROLE AS A COMPENSATED PHYSICIAN. STANLEY W SPINNER, MD 32.30 HOURS AVERAGE PER WEEK REPRESENTS HIS ROLE AS TEXAS CHILDREN'S PEDIACTRIC ASSOCIATES BOARD MEMBER (1 HOUR AVERAGE PER WEEK)AS WELL AS HIS ROLE AS A COMPENSATED PHYSICIAN. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CONTRIBUTED CAPITAL/PHYSICIAN PRACTICE 636,082. TRANSFER FROM TCH 297,574. TOTAL TO FORM 990, PART XI, LINE 5: 933,656. FORM 5471 DISCLOSURE STATEMENT: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCS). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT: -TEXAS CHILDREN'S HOSPITAL FOUNDATION EIN: 20-2380599 6621 FANIN ST HOUSTON, TX 77030 -TEXAS CHILDREN'S HOSPITAL EIN: 74-1100555 6621 FANIN ST HOUSTON, TX 77030 TEXAS CHILDREN'S MEDICAL GROUP 6621 FANNIN STREET HOUSTON TX 77030 741100555 INACTIVE TX 0 0 N/A TCH SYSTEM INC 1919 S BRAESWOOD BLVD HOUSTON TX 77030 760461578 HEALTH CARE TX 501(C)(3) LINE 11A, I TEXAS CHILDREN'S HOSPITAL 1 TEXAS CHILDREN'S PHYSICIAN GROUP INC 6621 FANNIN STREET HOUSTON TX 77030 260834681 HEALTH CARE TX 501(C)(3) LINE 9 TEXAS CHILDREN'S HOSPITAL 1 TEXAS CHILDREN'S HEALTH PLAN 2450 HOLCOMBE HOUSTON TX 77021 760486264 HEALTH CARE TX 501(C)(3) LINE 9 TEXAS CHILDREN'S HOSPITAL 1 TEXAS CHILDREN'S WOMEN'S SPECIALISTS PO BOX 300630 HOUSTON TX 77230 261482195 HEALTH CARE TX 501(C)(3) LINE 11A, I TEXAS CHILDREN'S HOSPITAL 1 TEXAS CHILDREN'S HOSPITAL 6621 FANNIN STREET HOUSTON TX 77030 741100555 HOSPITAL TX 501(C)(3) LINE 3 N/A 0 TEXAS CHILDREN'S HOSPITAL FOUNDATION 6621 FANNIN STREET HOUSTON TX 77030 202380599 SUPPORTING ORG TX 501(C)(3) LINE 11A, I TEXAS CHILDREN'S HOSPITAL 1 TCH INSURANCE COMPANY LTD 23 LIME BAY AVENUE KY1-1102 GRAND CAYMAN CJ INSURANCE CJ N/A C CVI GVF HOLDINGS 3 LTD UGLAND HOUSE SOUTH CHURCH STREET KY1-1104 GEORGE TOWN CJ INVESTMENT CJ N/A C 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1