Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
VIA CHRISTI IMMEDIATE CARE MOTHER MARY ANNE INC
Employer identification number
20-8374099
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
0
337,900
164,065
146,557
147,765
796,287
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
0
531,675
333,845
372,024
335,423
1,572,967
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
0
869,575
497,910
518,581
483,188
2,369,254
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
2,369,254
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
0
869,575
497,910
518,581
483,188
2,369,254
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
0
31
0
0
0
31
13
Total support (Add lines 9, 10c, 11 and 12.).
0
869,606
497,910
518,581
483,188
2,369,285
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
VIA CHRISTI IMMEDIATE CARE MOTHER MARY ANNE INC
Employer identification number
20-8374099
Identifier
Return Reference
Explanation
FORM 990 REVIEW
PART VI, SECTION A, QUESTION 11
THE ORGANIZATION USES VIA CHRISTI HOSPITALS WICHITA, INC.'S AUDIT COMMITTEE TO REVIEW THE FORM 990. THE AUDIT COMMITTEE REVIEWS AND APPROVES THE FORM 990 PRIOR TO THE DATE OF FILING. THE AUDIT COMMITTEE REPORTS ON THE REVIEW TO THE BOARD OF TRUSTEES AND ASSURES THAT THE BOARD HAS THE OPPORTUNITY TO REVIEW THE FINAL FORM 990 AS FILED. A COPY OF FORM 990 IS PROVIDED TO THE BOARD OF TRUSTEES VIA A SECURE EMAIL PRIOR TO FILING WITH THE IRS.
CONFLICT OF INTEREST POLICY
PART VI, SECTION B, QUESTION 12C
THE ORGANIZATION MONITORS AND ENFORCES ITS POLICY AS PART OF THE SYSTEM-WIDE PROCEDURE OF VIA CHRISTI HEALTH, INC. AND NOT AT THE ORGANIZATIONAL LEVEL. THE ORGANIZATION MONITORS AND ENFORCES THE CONFLICT OF INTEREST POLICY AS FOLLOWS: 1) AT TIME OF APPOINTMENT AND ANNUALLY THEREAFTER, ALL INTERESTED PERSONS, INCLUDING BOARD AND COMMITTEE MEMBERS COMPLETE A DISCLOSURE STATEMENT WHICH ADDRESSES ACTUAL OR POTENTIAL CONFLICTS OF INTEREST. 2) THE DISCLOSURE STATEMENT IS DONE ELECTRONICALLY AND THE RETURN OF THE COMPLETED STATEMENT IS A CONDITION OF CONTINUED APPOINTMENT, EMPLOYMENT OR PARTICIPATION WITH THE ORGANIZATION. 3) ALL ACTUAL OR POTENTIAL CONFLICTS ARE REVIEWED, INVESTIGATED AND RESOLVED BY THE CHIEF GOVERNANCE OFFICER AND THE CORPORATE RESPONSIBILITY OFFICER, WITH THE RESULTS SHARED WITH THE CHIEF EXECUTIVE OF THE ORGANIZATION. 4) PERIODIC REVIEWS ARE CONDUCTED BY GOVERNANCE, COMPLIANCE AND INTERNAL AUDIT TO ENSURE THE ORGANZIATION IS OPERATING CONSISTENT WITH THE POLICY AND ENFORCING THE POLICY'S TERMS.
COMPENSATION REVIEW
PART VI, SECTION B, QUESTION 15
The organization follows the same compensation review process as Via Christi Health, Inc.(VCH) VCH has established a common philosophy, strategy, and processes for executive compensation. Through the oversight of the VCH Executive Compensation Committee, executive compensation is competitively positioned at its stated market position when compared to the compensation paid by relevant organizations (comparably-sized health systems, hospitals, and long-term care providers). VCH recognizes its responsibility to ensure that its executive compensation program is appropriate in view of its mission and tax-exempt status and that its compensation levels and expenditures are reasonable and not excessive. To ensure these ends, the VCH Executive Compensation Committee has established and approved the executive compensation philosophy for VCH and all related entities. It will also approve all changes in the compensation package for VCH executives in advance. On an annual basis, the Committee conducts a comprehensive review of total compensation for all executives. It also reviews and approves "off-cycle" compensation transactions as needed. In their review, the Committee considers the following factors: * Market data from independent compensation surveys and sources that reflect comparable positions in organizations of similar size and scope * Difficulties in recruiting and retaining executives * Skills, experience and performance history of individual executives * Critical business or strategic issues that the organization may face * Market position for total compensation The adequacy, competitiveness, and cost of the VCH total executive compensation program are reviewed on an ongoing basis and changes are made as the Committee determines appropriate. The executive compensation program will be maintained such that it will fall within the safe harbor guidelines established by the Intermediate Sanctions regulations. The Committee also employs the services of an independent compensation consultant to prepare market analysis to aid and support the Committee's actions, provide documentation of market trends for budget setting purposes, review annual compensation changes to ensure "reasonableness" and provide attestation, and provide consultation on all executive compensation issues. The Committee also relies on third-party validation of performance measures used in the determination of compensation.
GOVERNING DOCUMENTS
PART VI, SECTION C, QUESTION 19
VIA CHRISTI IMMEDIATE CARE, MOTHER MARY ANNE, INC.'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
MEMBERS
PART VI, QUESTIONS 6 & 7A & 7B
VIA CHRISTI HOSPITALS WICHITA, INC. IS THE SOLE MEMBER. THE MEMBER HAS THE POWER TO REMOVE A TRUSTEE WITH OR WITHOUT NOTICE AND APPOINT A TRUSTEE. DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY THE MEMBERS, STOCKHOLDERS, AND OTHER PERSONS.
INTERNAL BOARD OF TRUSTEES
PART VI, SECTION A, 1B
THE ORGANIZATION'S BOARD CONSISTS MOSTLY OF INTERNAL VIA CHRISTI STAFF. ALL TRUSTEES, WITH THE EXCEPTION OF SISTER BARBARA RAMISCH, ARE EMPLOYEES OF THE ORGANIZATION.
RELATED TAX-EXEMPT ORGANIZATIONS
SCHEDULE R, PART II
VIA CHRISTI IMMEDIATE CARE, MOTHER MARY ANNE CLINIC, INC. IS INDIRECTLY CONTROLLED BY VIA CHRISTI HEALTH, INC. VIA CHRISTI HEALTH, INC. IS JOINTLY SPONSORED AND CONTROLLED BY ASCENSION HEALTH AND MARIAN HEALTH SYSTEM, WHICH IN TURN ARE SPONSORED BY THE SISTERS OF THE SORROWFUL MOTHER, FOUR PROVINCES OF THE DAUGHTERS OF CHARITY, THE CONGREGATION OF ST. JOSEPH, AND THE SISTERS OF ST. JOSEPH OF CARONDELET. DUE TO SUCH SPONSORSHIP AND CONTROL, AND IN THE INTEREST OF INCREASED CLARITY AND TRANSPARENCY, BOTH ASCENSION HEALTH AND MARIAN HEALTH SYSTEM ARE BEING LISTED AS RELATED ORGANIZATIONS ON SCHEDULE R.
EMPLOYEES
PART V, QUESTION 2A
VIA CHRISTI IMMEDIATE CARE MOTHER MARY ANNE, INC. DID NOT FILE FORM W-3. ALL EMPLOYEES ARE PAID BY A RELATED ORGANIZATION.