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PICKAWAY HEALTH SERVICES: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
PICKAWAY HEALTH SERVICES (EIN 31-1438107)
Tax period
2011-01-01 to 2011-12-31
Filed
2012-08-14
IRS object ID
201232279349301568
Schema version
2011v1.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2012-08-14T10:37:29-05:00Timestamp
Tax Period End Date2011-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN381357951EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1PLANTE & MORAN PLLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line165 EAST STATE STREET SUITE 600AddressLine1
CityCOLUMBUSCity
StateOHState
ZIP Code43215ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN311438107EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1PICKAWAY HEALTH SERVICES CO BERGER HEALTH SYSTEMBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlPICKNameControl
Phone7404208002Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1600 N PICKAWAY STREETAddressLine1
CityCIRCLEVILLECity
StateOHState
ZIP Code43113ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameTHOMAS SCHERERName
TitleVP OF FINANCETitle
Phone7404208002Phone
Date Signed2012-08-14DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameBERNIE OSTROWSKIName
PTINP00366367PTIN
Phone6148493000Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonTHOMAS SCHERERNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1600 N PICKAWAY STREETAddressLine1
CityCIRCLEVILLECity
StateOHState
ZIP Code43113ZIPCode
FieldValueIRS element (for citing)
Gross Receipts10650353GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.PICKAWAYHEALTHSERVICES.COMWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1995YearFormation
State Legal DomicileOHStateLegalDomicile
Activity Or Mission DescriptionTO ATTRACT AND RETAIN QUALIFIED HEALTHCARE PROFESSIONALS TO MEET THE EXPANDING HEALTHCARE NEEDS OF PICKAWAY COUNTY IN A MANNER THAT IS COMPASSIONATE, EXCEEDS PATIENT SERVICE EXPECTATIONS AND RESULTS IN A FINANCIALLY SELF-SUSTAINING ORGANIZATION.ActivityOrMissionDescription
Nbr Voting Members Governing Body11NbrVotingMembersGoverningBody
Nbr Independent Voting Members7NbrIndependentVotingMembers
Total Nbr Employees99TotalNbrEmployees
Total Nbr Volunteers7TotalNbrVolunteers
Total Gross UBI6883TotalGrossUBI
Net Unrelated Business Txbl Income-1453NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year5006582ContributionsGrantsPriorYear
Contributions Grants Current Year3957287ContributionsGrantsCurrentYear
Program Service Revenue Prior Year5586151ProgramServiceRevenuePriorYear
Program Service Revenue CY6646574ProgramServiceRevenueCY
Investment Income Prior Year0InvestmentIncomePriorYear
Investment Income Current Year0InvestmentIncomeCurrentYear
Other Revenue Prior Year18167OtherRevenuePriorYear
Other Revenue Current Year46492OtherRevenueCurrentYear
Total Revenue Prior Year10610900TotalRevenuePriorYear
Total Revenue Current Year10650353TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY50GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year6881294SalariesEtcPriorYear
Salaries Etc Current Year7174838SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year3104396OtherExpensePriorYear
Other Expenses Current Year3559327OtherExpensesCurrentYear
Total Expenses Prior Year9985690TotalExpensesPriorYear
Total Expenses Current Year10734215TotalExpensesCurrentYear
Revenues Less Expenses Prior Year625210RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-83862RevenuesLessExpensesCY
Total Assets BOY1562109TotalAssetsBOY
Total Assets EOY1543463TotalAssetsEOY
Total Liabilities BOY784684TotalLiabilitiesBOY
Total Liabilities EOY844831TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY777425NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY698632NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTO ATTRACT AND RETAIN QUALIFIED HEALTHCARE PROFESSIONALS TO MEET THE EXPANDING HEALTHCARE NEEDS OF PICKAWAY COUNTY IN A MANNER THAT IS COMPASSIONATE, EXCEEDS PATIENT SERVICE EXPECTATIONS AND RESULTS IN A FINANCIALLY SELF-SUSTAINING ORGANIZATION. ALSO, TO BE THE PREMIER GROUP OF HEALTHCARE PROFESSIONALS OF CHOICE WITHIN PICKAWAY AND SURROUNDING COUNTIES.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense1958831Expense
Grants0Grants
Revenue1547894Revenue
DescriptionTHE FAMILY PRACTICE OFFERS A FULL RANGE OF MEDICAL SERVICES IN ADDITION TO COMMUNITY EDUCATION AND WELLNESS PROJECTS CONSISTENT WITH THE CHARITABLE PURPOSE OF A 501(C)(3) ENTITY.Description

Activity2 Activity2

FieldValueIRS element (for citing)
Expense2179109Expense
Grants0Grants
Revenue1441962Revenue
DescriptionTHE OB/GYN PRACTICE OFFERS A FULL RANGE OF SERVICES CONSISTENT WITH THE CHARITABLE PURPOSE OF A 501(C)(3) ENTITY.Description

Activity3 Activity3

FieldValueIRS element (for citing)
Expense1722615Expense
Grants0Grants
Revenue1312366Revenue
DescriptionINTERNAL MEDICINE OFFERS A FULL RANGE OF SERVICES CONSISTENT WITH THE CHARITABLE PURPOSE OF A 501(C)(3) ENTITY.Description

Activity Other ActivityOther

FieldValueIRS element (for citing)
Expense2980781Expense
Grants0Grants
Revenue2371317Revenue
FieldValueIRS element (for citing)
Total Of Other Program Service Exp2980781TotalOfOtherProgramServiceExp
Total Of Other Program Service Rev2371317TotalOfOtherProgramServiceRev
Total Program Service Expense8841336TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities1ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity1RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10969NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees99NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members11NbrVotingGoverningBodyMembers
Number Independent Voting Members7NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledOHStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1JACK KENNEDYBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7404208006TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11180 N COURT STAddressLine1
CityCIRCLEVILLECity
StateOHState
ZIP Code43113ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (20 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficerHighest Compensated EmployeeHighestCompensatedEmployeeFormerFormer
DOROTHY JONES
DIRECTOR3.00X000
CALVIN GEBHART
DIRECTOR3.00X000
CHRISTY ALONZO
DIRECTOR3.00X000
LISA DUBOS
CHAIRPERSON/DIRECTOR3.00X000X
MADELINE SANDERS
DIRECTOR3.00X000
ANNETTE PERRY
CNP/DIRECTOR40.00X7506403789
FAROOQ SATTAR MD
PHYSICIAN/DIRECTOR40.00X350465021299
FRANKLIN CHRISTMAN
VILLAGE OF ASHVILLE - ADMIN3.00X000
JAMES MOSLEY MD
PHYSICIAN/DIRECTOR40.00X192151021233
LARRY SCHEIBER
DIRECTOR3.00X000
TIM COLBURN
PRESIDENT/CEO - BERGER HEALTH SYSTEM4.00X025694237912X
WENDY ELLIOTT
EXECUTIVE DIRECTOR40.0015215506785X
DAVID PAUGH
CFO - BERGER HEALTH SYSTEM4.00014399836666X
SALLY GALECKI
INTERIM EXECUTIVE DIRECTOR40.006082802474X
DAVID GOLDFARB MD
PHYSICIAN40.00490945270022304X
YADWINDER SINGH MD
PHYSICIAN40.00316117021395X
JOY LEVERICH MD
PHYSICIAN40.00257868012574X
ARNOLD PALMER DO
PHYSICIAN40.00255956600021395X
ALAN WARD MD
PHYSICIAN40.00251290021395X
LEAH MADERIA ADKINS MD
FORMER DIRCT/HIGHEST COMP EMPLOYEE40.0013481505806X
FieldValueIRS element (for citing)
Total Reportable Comp From Org2537654TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs409640TotalReportableCompFrmRltdOrgs
Total Other Compensation235027TotalOtherCompensation
Number Individuals GT100 K21NumberIndividualsGT100K
Formers Listed1FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (2 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
DELL PEROTADVANCED RECEIVABLES
12020 COLLECTIONS CENTER DRIVECHICAGOIL60693BILLING SERVICES633739
GE HEALTHCARE
15724 COLLECTIONS CENTER DRIVECHICAGOIL60693OPERATING SYSTEM CONSULTANT344926
FieldValueIRS element (for citing)
Number Of Contractors GT100 K2NumberOfContractorsGT100K
Related Organizations3957287RelatedOrganizations
Total Contributions3957287TotalContributions

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionPHYSICIAN SERVICESDescription
Business Code621110BusinessCode
Total Revenue Column6646574TotalRevenueColumn
Related Or Exempt Function Income6646574RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue6646574TotalProgramServiceRevenue

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncomeExclusionExclusionAmountUnrelated Business RevenueUnrelatedBusinessRevenue
MEDICAL RECORD FEES6211101536315363
PURCHASE DISCOUNTS62111012644$12,644
BILLING SERVICE56100068836883

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column11602TotalRevenueColumn
Related Or Exempt Function Income11602RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Other Revenue46492TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column10650353TotalRevenueColumn
Related Or Exempt Function Income6673539RelatedOrExemptFunctionIncome
Unrelated Business Revenue6883UnrelatedBusinessRevenue
Exclusion$12,644ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total50Total
Program Services50ProgramServices

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total1075473Total
Program Services752319ProgramServices
Management And General323154ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total5134129Total
Program Services4826082ProgramServices
Management And General308047ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total79384Total
Program Services55569ProgramServices
Management And General23815ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total535955Total
Program Services455562ProgramServices
Management And General80393ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total349897Total
Program Services321906ProgramServices
Management And General27991ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total729125Total
Management And General729125ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total6069Total
Management And General6069ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total41712Total
Management And General41712ManagementAndGeneral

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total27861Total
Management And General27861ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total410700Total
Program Services336774ProgramServices
Management And General73926ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total780Total
Program Services780ProgramServices

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1547443Total
Program Services1346277ProgramServices
Management And General201166ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total119Total
Program Services102ProgramServices
Management And General17ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total2766Total
Program Services2489ProgramServices
Management And General277ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total4336Total
Program Services1691ProgramServices
Management And General2645ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total71133Total
Program Services61174ProgramServices
Management And General9959ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total141224Total
Program Services120040ProgramServices
Management And General21184ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total310765Total
Program Services295227ProgramServices
Management And General15538ManagementAndGeneral

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionBAD DEBT EXPENSEDescription
Total265294Total
Program Services265294ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total10734215Total
Program Services8841336ProgramServices
Management And General1892879ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY-60791BOY
EOY0EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY606278BOY
EOY678938EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY109714BOY
EOY0EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis1238419LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec579092LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY701833BOY
EOY659327EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY200130BOY
EOY205198EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY4945BOY
EOY0EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY1562109BOY
EOY1543463EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY784684BOY
EOY844831EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY784684BOY
EOY844831EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY777425BOY
EOY698632EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY777425BOY
EOY698632EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY1562109BOY
EOY1543463EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses-83862ReconcilationRevenueExpenses
Reconcilation Other Changes5069ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee0AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3XSupportingOrganization509a3
Supporting Org509a3 Type1XSupportingOrg509a3Type1
Certification CheckboxXCertificationCheckbox
Contrib By Controlling Individual0ContribByControllingIndividual
Contribution By Related Party0ContributionByRelatedParty
Contrib By35 Controlled Entity0ContribBy35ControlledEntity

Supported Org Information SupportedOrgInformation

Name Name

FieldValueIRS element (for citing)
Business Name Line1BERGER HEALTH SYSBusinessNameLine1
FieldValueIRS element (for citing)
EIN316400103EIN
Type Of Organization6TypeOfOrganization
Listed In Governing Doc1ListedInGoverningDoc
Supported Organization Notified1SupportedOrganizationNotified
Organized In US1OrganizedInUS
Amount$0Amount
FieldValueIRS element (for citing)
Total Number Of Supported Orgs1TotalNumberOfSupportedOrgs
Sum Of Amounts0SumOfAmounts

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis1597OtherCostOrOtherBasis
Depreciation1597Depreciation
Book Value0BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis27716OtherCostOrOtherBasis
Depreciation27716Depreciation
Book Value0BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis1209106OtherCostOrOtherBasis
Depreciation549779Depreciation
Book Value659327BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings659327TotalOfBookValueLandBuildings

Other Securities OtherSecurities

FieldValueIRS element (for citing)
DescriptionINVESTMENT IN OHAISDescription
Book Value205198BookValue
Method Of ValuationFMethodOfValuation
FieldValueIRS element (for citing)
Total Of Book Value Securities205198TotalOfBookValueSecurities

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (11 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
FAROOQ SATTAR MD
3504650000050000162990371764000
JAMES MOSLEY MD
1921510000050000162330213384000
TIM COLBURN
0256942000003597201940029485400
WENDY ELLIOTT
146155060000005000017850158940000
DAVID PAUGH
01439980000020160016506018066400
DAVID GOLDFARB MD
4909450000270050000173040513249270000
YADWINDER SINGH MD
3161170000050000163950337512000
JOY LEVERICH MD
257868000005000075740270442000
ARNOLD PALMER DO
2559560000600050000163950277351600000
ALAN WARD MD
2512900000050000163950272685000
LEAH MADERIA ADKINS MD
13481500000500008060140621000

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 6PICKAWAY HEALTH SERVICES IS ORGANIZED AS A COMPONENT UNIT OF BERGER HEALTH SYSTEM, THE PARENT ORGANIZATION AND MEMBER OF THE CONSOLIDATED GROUP.
FORM 990, PART VI, SECTION A, LINE 7APICKAWAY HEALTH SERVICES BOARD OF DIRECTORS ARE APPROVED BY THE BOARD OF DIRECTORS OF BERGER HOSPITAL.
FORM 990, PART VI, SECTION B, LINE 11THE 2011 FORM 990 IS REVIEWED FOR COMPLETENESS AND ACCURACY BY BOTH THE EXECUTIVE DIRECTOR AND VP OF FINANCE. THE FORM 990 IS PROVIDED TO AND REVIEWED BY THE BOARD PRIOR TO FILING THE RETURN WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12CTHE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THEIR CONFLICT OF INTEREST POLICY BY DISTRIBUTING ANNUAL QUESTIONNAIRES TO THE BOARD MEMBERS, DIRECTORS, AND OFFICERS. NEW BOARD MEMBERS COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY. THE QUESTIONNAIRES MUST BE SIGNED AND RETURNED TO PICKAWAY HEALTH SERVICES TO BE FILED FOR FURTHER REVIEW BY THE PRESIDENT/CEO OF BERGER HEALTH SYSTEM. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE RESPECTIVE BOARDS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A CONFLICTS OF INTEREST STATEMENT BY A BOARD MEMBER, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE BOARD MEMBER, THE BOARD SHALL REVIEW THE MATTER TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE CONFLICTED BOARD MEMBER SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE BOARD CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, BOARD MEMBERS SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE RESPECTIVE BOARDS FOR DISCUSSION AND VOTE. THE CONFLICTED BOARD MEMBER MAY NOT BE PRESENT AND MUST ABSTAIN FROM VOTING WHEN THIS VOTE IS TAKEN.
FORM 990, PART VI, SECTION B, LINE 15THE ORGANIZATION'S COMPENSATION FOR THE EXECUTIVE DIRECTOR AND OTHER OFFICERS IS DETERMINED BY USING DATA FROM THE MEDICAL GROUP MANAGEMENT ASSOCIATION. THE EXECUTIVE DIRECTOR'S COMPENSATION IS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS. THE CFO'S COMPENSATION IS REVIEWED AND APPROVED BY THE PRESIDENT/CEO OF BERGER HEALTH SYSTEM. DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATION AND DECISIONS IS KEPT CONTEMPORANEOUSLY WITHIN THE MINUTES TO THE BOARD OF DIRECTORS MEETINGS; THIS PROCESS WAS LAST COMPLETED IN 2009.
FORM 990, PART VI, SECTION C, LINE 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AND THROUGH THE ORGANIZATION'S WEBSITE.
FORM 990, PART XI, LINE 5:NET UNREALIZED GAINS ON INVESTMENTS: 5,069.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XII, LINE 2C:BERGER HEALTH SYSTEM ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT.
FORM 990, PART VIIESTIMATE OF OFFICERS' ALLOCATION OF HOURS WORKED FOR PICKAWAY HEALTH SERVICES RELATED ENTITIES: BERGER HEALTH FOUNDATION: -TIM COLBURN: 3 HOURS -DAVID PAUGH: 3 HOURS PICKAWAY PROFESSIONAL SERVICES, INC.: -TIM COLBURN: 2 HOURS -DAVID PAUGH: 2 HOURS BERGER HEALTH FOUNDATION VENTURES: -TIM COLBURN: 1 HOURS -DAVID PAUGH: 1 HOURS BERGER HOSPITAL: -TIM COLBURN: 40 HOURS -DAVID PAUGH: 40 HOURS -WENDY ELLIOTT: 2 HOURS

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (3 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusDirect Controlling Entity NADirectControllingEntityNAControlled OrgControlledOrgBusiness Name Line1DirectControllingEntityName/BusinessNameLine1
BERGER HOSPITAL
600 N PICKAWAY STCIRCLEVILLEOH43113316400103ACUTE CARE HOSPITALOHGOVERNMENTAL HOSPITAN/AN/A0
BERGER HEALTH FOUNDATION
600 N PICKAWAY STCIRCLEVILLEOH43113331031454SUPPORTS THE HOSPITAL AND COMMUNITY PROGRAMSOH501 C(3)LINE 71BERGER HOSPITAL
BERGER HEALTH SYSTEM
600 N PICKAWAY STCIRCLEVILLEOH43113262545110INACTIVE ACUTE CARE HOSPITALOH501 C(3)LINE 3N/A0

Form990 Schedule R Part III Form990ScheduleRPartIII (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivityPrimaryActivityLegal Domicile StateLegalDomicileStateDirect Controlling Entity NADirectControllingEntityNA
BERGER ACUTE SERVICES LLC
332 CONGRESS PARK DRDAYTONOH45459451450450MEDICAL SERVICESOHN/A
PICKAWAY DIALYSIS CENTER LLC
66 CHERRY HILL DRIVEBEVERLYMA01915562614118DIALYSISMAN/A

Form990 Schedule R Part IV Form990ScheduleRPartIV (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivityPrimaryActivityLegal Domicile StateLegalDomicileStateDirect Controlling Entity NADirectControllingEntityNAType Of EntityTypeOfEntity
PICKAWAY PROFESSIONAL SERVICES INC
600 N PICKAWAY STCIRCLEVILLEOH43113611408162ANESTHESIOLOGISTSOHN/AC
BERGER HEALTH FOUNDATION VENTURES
1204 N COURT STCIRCLEVILLEOH43113412218009MEDICAL SERVICESOHN/AC
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org1GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs1RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (3 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolvedMethod Of Amt DeterminationMethodOfAmtDetermination
BERGER HOSPITAL
C3957287CASH TRANSACTION
BERGER HOSPITAL
J629329LEASE CONTRACTS
BERGER HOSPITAL
L65634ACTUAL COST