2011-06-01T08:35:58-05:00 2010-09-30 DIXON HUGHES GOODMAN LLP 500 Ridgefield Court Asheville NC 28806 990 2009-10-01 561925492 ROANOKE VALLEY HEALTH SERVICES INC ROAN 2525358130 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 SHERRY JENSEN 2525358130 2011-05-31 1 Michael Rauchwarg 8282542254 2009 2016-02-24 21:20:13Z SHERRY JENSEN 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 3744951 0 X WWW.HALIFAXMEDICALCENTER.ORG X 1994 NC OPERATION OF PRIMARY CARE MEDICAL OFFICES 26 22 54 34 0 0 68180 57804 4979193 3163247 41 310 51627 523590 5099041 3744951 0 0 4095585 4401890 0 0 4707142 932283 8802727 5334173 -3703686 -1589222 2991370 1760796 11930333 12288981 -8938963 -10528185 ROANOKE VALLEY HEALTH SERVICES EXISTS TO MEET THE HEALTHCARE NEEDS OF OUR COMMUNITY BY PROVIDING EXCELLENT AND COMPASSIONATE SERVICES AND ALWAYS PLACING PATIENTS FIRST. 0 0 4522504 3628846 ROANOKE VALLEY HEALTH SERVICES, INC. OPERATES NON-PROFIT PRIMARY CARE MEDICAL OFFICES. THE ORGANIZATION WORKS IN CLOSE TIES WITH HALIFAX REGIONAL MEDICAL CENTER, AND SHARES IN ITS GOALS AND ACHIEVEMENTS THROUGH A CONSTANT PARTNERSHIP OF FULFILLING THE HOSPITAL'S EXEMPT PURPOSE--PROVIDING EXCELLENT HEALTHCARE SERVICE TO THE COMMUNITY. 4522504 1 1 0 0 0 0 0 0 0 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 0 0 0 1 0 0 54 1 0 0 0 0 0 0 0 0 0 26 22 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 NC X SHERRY JENSEN 2525358005 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 X JOHNNY DRAPER 1.00 X X 0 1100 0 VERNON BRYANT 1.00 X X 0 1100 0 TOM LYNCH 1.00 X X 0 1000 0 BOB PATTERSON 1.00 X X 0 950 0 J HUGH BAZEMORE 1.00 X 0 1000 0 DRGERARDO MARADIAGA 1.00 X 0 0 0 DR SHIVA RAO 1.00 X 0 0 0 ERNEST BARNER 1.00 X 0 650 0 DREWERY BEALE 1.00 X 0 750 0 WILLIAM HODGE 1.00 X 0 1100 0 REV JOHN W SMITH 1.00 X 0 150 0 EVELYN DAWSON 1.00 X 0 500 0 FANNIE GREENE 1.00 X 0 150 0 NEAL PHILLIPS 1.00 X 0 200 0 JAMES PIERCE 1.00 X 0 0 0 WILL MAHONE 1.00 X X 0 295786 56578 SHERRY JENSEN 1.00 X X 0 208597 29218 CARL FEREBEE 1.00 X X 0 91416 12289 MICHAEL E GILSTRAP 1.00 X X 0 0 0 KAREN DANIELS 1.00 X X 0 173505 32170 MICHAEL ADCOCK 1.00 X X 0 61606 6953 CONNIE HILL 1.00 X 0 0 0 ROSE FLEMING 1.00 X 0 0 0 RUBY PALMER 1.00 X 0 0 0 GORDON ROGERS 1.00 X 0 0 0 REV MARJORIE HOLM 1.00 X 0 0 0 BETTY COOK 1.00 X 0 34488 1199 DR KENNETH ROBERT 1.00 X 0 194099 16465 GEOFFREY HARDEE 1.00 X 0 0 0 MOHAMAD SHAKIR 40.00 X 273128 0 18197 SYED AHMED 40.00 X 237648 0 17893 ASRA JAFFAR 40.00 X 205435 0 7279 BIRHANE KALEAB 40.00 X 197126 0 14031 CHINEDU ONUORAH 40.00 X 196659 0 2995 1109996 1068147 215267 5 0 1 0 0 57804 57804 NET PATIENT SERVICE RE 621610 3163247 3163247 3163247 310 310 BAD DEBT RECOVERY 900099 465599 465599 Other Revenue 900099 57991 57991 523590 3744951 3628846 0 58301 3666943 3094902 572041 551645 465589 86056 183302 154707 28595 377085 377085 3549 3549 230300 199476 30824 21598 21598 33672 33672 45835 45835 97338 97338 26215 26215 RECRUITMENT AND RELOCAT 94153 94153 OTHER EXPENSES 2538 2538 5334173 4522504 811669 0 206347 272144 1339130 402195 65593 1884 1713624 648655 1109329 1064969 270971 19604 2991370 1760796 81131 142616 11849202 12146365 11930333 12288981 X -8996851 -10573070 57888 44885 -8938963 -10528185 2991370 1760796 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1165929 478979 686950 131202 53900 77302 281822 115776 166046 134671 134671 1064969 OTHER RECEIVABLES 18339 ESTIMATED THIRD PARTY SETTLEMENTS 1265 19604 DUE TO HALIFAX REGIONAL MEDICAL CENTER 12146365 12146365 3744951 5334173 -1589222 0 -1589222 3279352 0 3279352 465599 465599 3744951 4868574 -465599 -465599 5334173 0 5334173 Part XII, Line 4b - Other Adjustments: RECOVERY OF BAD DEBTS: 465599. Part XIII, Line 2d - Other Adjustments: RECOVERY OF BAD DEBTS: -465599. 0 0 0 0 0 0 0 1 0 WILL MAHONE 0 251000 0 36783 0 8003 0 38562 0 18016 0 352364 0 0 SHERRY JENSEN 0 183285 0 22754 0 2558 0 14905 0 14313 0 237815 0 0 KAREN DANIELS 0 152654 0 18808 0 2043 0 22000 0 10170 0 205675 0 0 DR KENNETH ROBERT 0 184169 0 9544 0 386 0 0 0 16465 0 210564 0 0 MOHAMAD SHAKIR 246238 0 26327 0 563 0 0 0 18197 0 291325 0 0 0 SYED AHMED 224644 0 12692 0 312 0 0 0 17893 0 255541 0 0 0 ASRA JAFFAR 205108 0 15 0 312 0 0 0 7279 0 212714 0 0 0 BIRHANE KALEAB 176598 0 20010 0 518 0 0 0 14031 0 211157 0 0 0 CHINEDU ONUORAH 171356 0 25010 0 293 0 0 0 2995 0 199654 0 0 0 Part I, Line 7 THE OFFICERS LISTED BELOW ARE RECIPIENTS OF NON-FIXED PAYMENTS FROM A RELATED ORGANIZATION (HALIFAX REGIONAL MEDICAL CENTER, INC.). THE CEO AND VICE PRESIDENT RECEIVE AT-RISK SALARY PAYMENTS FROM THIS RELATED ORGANIZATION BASED ON REACHING BALANCED SCORECARD OBJECTIVES. THE AMOUNT AVAILABLE IS THE AT-RISK SALARY AVAILABLE FOR THE INDIVIDUAL POSITIONS. FOR 2009, THE FOLLOWING OFFICERS RECEIVED PAYMENTS UNDER THIS PLAN: WILL MAHONE $ 36,783 SHERRY JENSEN 22,754 KAREN DANIELS 18,808 Supplemental Information Part III PART I, LINE 3: INDEPENDENT REVIEW OF COMPENSATION: THE ORGANIZATION DOES NOT DIRECTLY COMPENSATE ANY OFFICER OR KEY EMPLOYEE. SOME OFFICERS AND BOARD MEMBERS OF THE ORGANIZATION ARE EMPLOYEES OF HALIFAX REGIONAL MEDICAL CENTER, INC., A RELATED ORGANIZATION. THE BOARD OF DIRECTORS OF THAT ORGANIZATION USES THE FOLLOWING METHODS TO ESTABLISH COMPENSATION AMOUNTS FOR ITS CEO AND OTHER KEY PERSONNEL: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANTS - WRITTEN EMPLOYEMENT CONTRACTS - COMPENSATION STUDY OR SURVEY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE Form 990, Part VI, Section B, line 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND INFORMATION PROVIDED BY MANAGEMENT. THE ORGANIZATION PROVIDED EVERY VOTING BOARD MEMBER A COPY OF THE DRAFT 990 PRIOR TO A SCHEDULED MEETING. DETAILS OF THE RETURN WERE DISCUSSED WITH MANAGEMENT AND THE FINANCE COMMITTEE OF THE BOARD, WHO THEN DELIVERED A REPORT TO THE FULL BOARD PRIOR TO FILING THE RETURN WITH THE IRS. Form 990, Part VI, Section B, line 12c THE ORGANIZATION FOLLOWS THE SAME CONFLICT OF INTEREST POLICY AS ITS AFFILIATE, HALIFAX REGIONAL MEDICAL CENTER. THE POLICY IS REVIEWED ANNUALLY, AND BOARD MEMBERS AND MANAGEMENT ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR. Form 990, Part VI, Section B, line 15a THE ORGANIZATION ENGAGES AN OUTSIDE INDEPENDENT PARTY FOR REVIEW OF COMPENSATION PACKAGES. THE CONSULTANT USES COMPARABLE POSITIONS AND BENCHMARKS TO EVALUATE THE SALARIES FOR THE CEO AND VICE PRESIDENTS. THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS THE CONSULTANT'S RECOMMENDATIONS, AND THE FULL BOARD APPROVES THE COMPENSATION PACKAGE SELECTED FOR THE CEO. THE CONSULTATION PROCESS FOR OTHER OFFICERS INVOLVES THE INDEPENDENT CONSULTANTS; HOWEVER, THE CEO HAS FINAL APPROVAL OVER COMPENSATION PACKAGES FOR VICE PRESIDENTS AND BELOW. Form 990, Part VI, Section C, line 18 RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON WRITTEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. Form 990, Part VI, Section C, line 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON WRITEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. HALIFAX REGIONAL MEDICAL CENTER 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 560989789 HEALTHCARE NC 501(C)(3) 3 HALIFAX REGIONAL MEDICAL CENTER FOUNDATION 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 561698825 FUNDRAISING/OPERATIONAL SUPPORT NC 501(C)(3) 7 HALIFAX REGIONAL MEDICAL CENTER 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0