2012-08-14T10:37:29-05:00 2011-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE STREET SUITE 600 COLUMBUS OH 43215 990 2011-01-01 311438107 PICKAWAY HEALTH SERVICES CO BERGER HEALTH SYSTEM PICK 7404208002 600 N PICKAWAY STREET CIRCLEVILLE OH 43113 THOMAS SCHERER 7404208002 2012-08-14 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z THOMAS SCHERER 600 N PICKAWAY STREET CIRCLEVILLE OH 43113 10650353 0 X WWW.PICKAWAYHEALTHSERVICES.COM X 1995 OH TO 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. 11 7 99 7 6883 -1453 5006582 3957287 5586151 6646574 0 0 18167 46492 10610900 10650353 0 50 0 0 6881294 7174838 0 0 0 3104396 3559327 9985690 10734215 625210 -83862 1562109 1543463 784684 844831 777425 698632 X TO 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. 0 0 1958831 0 1547894 THE 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. 2179109 0 1441962 THE OB/GYN PRACTICE OFFERS A FULL RANGE OF SERVICES CONSISTENT WITH THE CHARITABLE PURPOSE OF A 501(C)(3) ENTITY. 1722615 0 1312366 INTERNAL MEDICINE OFFERS A FULL RANGE OF SERVICES CONSISTENT WITH THE CHARITABLE PURPOSE OF A 501(C)(3) ENTITY. 2980781 0 2371317 2980781 2371317 8841336 1 1 0 0 0 0 0 0 0 0 1 1 0 0 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 1 0 0 0 1 9 0 1 99 1 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X JACK KENNEDY 7404208006 1180 N COURT ST CIRCLEVILLE OH 43113 DOROTHY JONES 3.00 X 0 0 0 CALVIN GEBHART 3.00 X 0 0 0 CHRISTY ALONZO 3.00 X 0 0 0 LISA DUBOS 3.00 X X 0 0 0 MADELINE SANDERS 3.00 X 0 0 0 ANNETTE PERRY 40.00 X 75064 0 3789 FAROOQ SATTAR MD 40.00 X 350465 0 21299 FRANKLIN CHRISTMAN 3.00 X 0 0 0 JAMES MOSLEY MD 40.00 X 192151 0 21233 LARRY SCHEIBER 3.00 X 0 0 0 TIM COLBURN 4.00 X X 0 256942 37912 WENDY ELLIOTT 40.00 X 152155 0 6785 DAVID PAUGH 4.00 X 0 143998 36666 SALLY GALECKI 40.00 X 60828 0 2474 DAVID GOLDFARB MD 40.00 X 490945 2700 22304 YADWINDER SINGH MD 40.00 X 316117 0 21395 JOY LEVERICH MD 40.00 X 257868 0 12574 ARNOLD PALMER DO 40.00 X 255956 6000 21395 ALAN WARD MD 40.00 X 251290 0 21395 LEAH MADERIA ADKINS MD 40.00 X 134815 0 5806 2537654 409640 235027 21 1 1 0 DELL PEROTADVANCED RECEIVABLES 12020 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 BILLING SERVICES 633739 GE HEALTHCARE 15724 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 OPERATING SYSTEM CONSULTANT 344926 2 3957287 3957287 PHYSICIAN SERVICES 621110 6646574 6646574 6646574 MEDICAL RECORD FEES 621110 15363 15363 PURCHASE DISCOUNTS 621110 12644 12644 BILLING SERVICE 561000 6883 6883 11602 11602 46492 10650353 6673539 6883 12644 50 50 1075473 752319 323154 5134129 4826082 308047 79384 55569 23815 535955 455562 80393 349897 321906 27991 729125 729125 6069 6069 41712 41712 27861 27861 410700 336774 73926 780 780 1547443 1346277 201166 119 102 17 2766 2489 277 4336 1691 2645 71133 61174 9959 141224 120040 21184 310765 295227 15538 BAD DEBT EXPENSE 265294 265294 10734215 8841336 1892879 0 -60791 0 606278 678938 109714 0 1238419 579092 701833 659327 200130 205198 4945 0 1562109 1543463 784684 844831 784684 844831 X 777425 698632 777425 698632 1562109 1543463 X -83862 5069 X X 0 1 0 X 0 X X X 0 0 0 BERGER HEALTH SYS 316400103 6 1 1 1 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1597 1597 0 27716 27716 0 1209106 549779 659327 659327 INVESTMENT IN OHAIS 205198 F 205198 X X X 0 0 0 0 0 0 0 0 0 FAROOQ SATTAR MD 350465 0 0 0 0 0 5000 0 16299 0 371764 0 0 0 JAMES MOSLEY MD 192151 0 0 0 0 0 5000 0 16233 0 213384 0 0 0 TIM COLBURN 0 256942 0 0 0 0 0 35972 0 1940 0 294854 0 0 WENDY ELLIOTT 146155 0 6000 0 0 0 5000 0 1785 0 158940 0 0 0 DAVID PAUGH 0 143998 0 0 0 0 0 20160 0 16506 0 180664 0 0 DAVID GOLDFARB MD 490945 0 0 0 0 2700 5000 0 17304 0 513249 2700 0 0 YADWINDER SINGH MD 316117 0 0 0 0 0 5000 0 16395 0 337512 0 0 0 JOY LEVERICH MD 257868 0 0 0 0 0 5000 0 7574 0 270442 0 0 0 ARNOLD PALMER DO 255956 0 0 0 0 6000 5000 0 16395 0 277351 6000 0 0 ALAN WARD MD 251290 0 0 0 0 0 5000 0 16395 0 272685 0 0 0 LEAH MADERIA ADKINS MD 134815 0 0 0 0 0 5000 0 806 0 140621 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 PICKAWAY 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 7A PICKAWAY HEALTH SERVICES BOARD OF DIRECTORS ARE APPROVED BY THE BOARD OF DIRECTORS OF BERGER HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE 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 12C THE 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 15 THE 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 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AND THROUGH THE ORGANIZATION'S WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 5,069. 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 VII ESTIMATE 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 BERGER HOSPITAL 600 N PICKAWAY ST CIRCLEVILLE OH 43113 316400103 ACUTE CARE HOSPITAL OH GOVERNMENTAL HOSPITA N/A N/A 0 BERGER HEALTH FOUNDATION 600 N PICKAWAY ST CIRCLEVILLE OH 43113 331031454 SUPPORTS THE HOSPITAL AND COMMUNITY PROGRAMS OH 501 C(3) LINE 7 BERGER HOSPITAL 1 BERGER HEALTH SYSTEM 600 N PICKAWAY ST CIRCLEVILLE OH 43113 262545110 INACTIVE ACUTE CARE HOSPITAL OH 501 C(3) LINE 3 N/A 0 BERGER ACUTE SERVICES LLC 332 CONGRESS PARK DR DAYTON OH 45459 451450450 MEDICAL SERVICES OH N/A PICKAWAY DIALYSIS CENTER LLC 66 CHERRY HILL DRIVE BEVERLY MA 01915 562614118 DIALYSIS MA N/A PICKAWAY PROFESSIONAL SERVICES INC 600 N PICKAWAY ST CIRCLEVILLE OH 43113 611408162 ANESTHESIOLOGISTS OH N/A C BERGER HEALTH FOUNDATION VENTURES 1204 N COURT ST CIRCLEVILLE OH 43113 412218009 MEDICAL SERVICES OH N/A C 0 0 1 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 BERGER HOSPITAL C 3957287 CASH TRANSACTION BERGER HOSPITAL J 629329 LEASE CONTRACTS BERGER HOSPITAL L 65634 ACTUAL COST