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
2012
Open to Public Inspection
Name of the organization
ROCKFORD HEALTH PHYSICIANS
Employer identification number
36-3907436
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 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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
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—2011.
If the organization did not check a 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—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
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......
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.
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.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
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.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
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 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012
Additional Data
Software ID:
12000266
Software Version:
v2012.1.0
-
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
2012
Open to Public Inspection
Name of the organization
ROCKFORD HEALTH PHYSICIANS
Employer identification number
36-3907436
Identifier
Return Reference
Explanation
Delegate broad authority to a committee
Form 990, Part VI, Section A, Line 1a
THE VOTING MEMBERS OF THE EXECUTIVE COMMITTEE SHALL BE THE THE FOLLOWING INDIVIDUALS, EACH OF WHOM SHALL HAVE A VOTE: RHS CEO, CHAIRMAN, VICE-CHAIRMAN, IMMEDIATE PAST CHAIRMAN, TREASURER AND TWO ADDITIONAL DIRECTORS. AT LEAST ONE MEMBER OF THE EXECUTIVE COMMITTEE SHALL BE A PHYSICIAN. THE EXECUTIVE COMMITTEE SHALL BE COMPRISED OF AT LEAST 51% COMMUNITY MEMBERS. THE EXECUTIVE COMMITTEE SHALL REVIEW REPORTS FROM THE RHS CEO REGARDING THE PERFORMANCE OF EXECUTIVES OF THE CORPORATION AND AFFILIATED CORPORATIONS, MONITOR THE PERFORMANCE OF THE RHS CEO OF THE CORPORATION AGAINST ANNUAL OBJECTIVES, AND DETERMINE THE COMPENSATION LEVEL OF THE RHS CEO. IN ADDITION, WHEN THE BOARD OF DIRECTORS IS NOT IN SESSION, THE EXECUTIVE COMMITTEE SHALL HAVE ALL THE POWERS, DUTIES, RESPONSIBILITIES AND AUTHORITY OF THE BOARD, EXCEPT AS PROHIBITED BY LAW.
Classes of members or stockholders
Form 990, Part VI, Section A, Line 6
ROCKFORD HEALTH SYSTEM (RHS) IS THE SOLE CORPORATE MEMBER OF ROCKFORD HEALTH PHYSICIANS (RHPH). THE SOLE MEMBER SHALL HAVE POWERS AND VOTING RIGHTS TO DO THE FOLLOWING: (A) APPOINT ALL THE DIRECTORS OF RHPH. (B) NOMINATE TO RHPH'S BOARD OF DIRECTORS ALL CANDIDATES FOR SELECTION AS THE RHPH PRESIDENT. (C) APPROVE EXPRESSLY ALL AMENDMENTS TO RHPH'S ARTICLES OF INCORPORATION AND BY-LAWS. (D) APPROVE ANNUAL BUDGETS, AND STRATEGIC, LONG-RANGE AND HEALTH MANPOWER DEVELOPMENT PLANS OF RHPH. (E) APPROVE ALL CONTRACTS (INCLUDING CONTRACTS OF INDEBTEDNESS) EFFECTIVE FOR LONGER THAN EIGHTEEN MONTHS. (F) APPROVE ALL PLANS OF MERGER OR CONSOLIDATION. (G) APPROVE THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF RHPH. (H) APPROVE A VOLUNTARY DISSOLUTION OF THE RHPH. (I) APPROVE MATERIAL AMENDMENTS TO RHPH'S STANDARD FORM OF PHYSICIAN EMPLOYMENT AGREEMENT. (J) APPROVE MATERIAL AMENDMENTS TO THE STANDARD COMPENSATION SYSTEM USED BY RHPH TO ESTABLISH INDIVIDUAL PHYSICIAN COMPENSATION. (K) REQUIRE RHPH TO TAKE ANY ACTION (INCLUDING AMENDING THE ARTICLES OF INCORPORATION OR BY-LAWS), OR TO MODIFY OR RESCIND AN ACTION ALREADY TAKEN, IF RHS DETERMINES THAT FAILURE TO TAKE THE ACTION, OR TO MODIFY OR RESCIND AN ACTION ALREADY TAKEN, MAY RESULT IN THE MEMBER'S OR RHPH'S FAILURE TO OBTAIN OR MAINTAIN ITS EXEMPTION AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE CODE.
Members or stockholders electing members of governing body
Form 990, Part VI, Section A, Line 7a
SEE NARRATIVE FOR PART VI, LINE 6
Decisions requiring approval by members or stockholders
Form 990, Part VI, Section A, Line 7b
SEE NARRATIVE FOR PART VI, LINE 6
Review of form 990 by governing body
Form 990, Part VI, Section B, Line 11b
THE DATE WAS GATHERED BY THE ACCOUNTING STAFF WITH INPUT FROM RHPH AND RHS EXECUTIVE STAFFS. THE DATA WAS REVIEWED AND THE FORM 990 PREPARED BY THE RHPH STAFF. ONCE THE FORM 990 WAS MADE AVAILABLE IT WAS REVIEWED BY AN INDEPENDENT ACCOUNTING FIRM. A COPY OF THE FORM 990 WAS MADE AVAILABLE TO ALL BOARD MEMBERS ON A SECURE INTERCOMPANY WEBSITE.
Conflict of interest policy
Form 990, Part VI, Section B, Line 12c
RHS COMPLIANCE DEPARTMENT (ACTING ON BEHALF OF RHPH) IS REQUIRED TO ANNUALLY SEND OUT A COPY OF THE POLICY WITH THE CONFLICT OF INTEREST FORM INCLUDED. EACH MEMBER IS TO COMPLETE THE FINANCIAL INTEREST DISCLOSURE STATEMENT WHICH IS PART OF THE POLICY. THE RHS COMPLIANCE DEPARTMENT REVIEWS AND RETAINS THESE STATEMENTS. IF A CONFLICT IS IDENTIFIED, ALL AFFECTED PARTIES ARE INFORMED, POTENTIAL CONFLICTS ARE REVIEWED AND APPROPRIATE ACTIONS ARE TAKEN AS A RESULT OF THE REVIEW. EMPLOYEES ARE GIVEN THE POLICY AND STATEMENT TO COMPLETE AT THE BEGINNING OF THE YEAR OR AS A NEW PARTY IS HIRED OR JOINS THE RHPH BOARD. THIS PROCESS IS COMPLETED ANNUALLY, AND WAS LAST PERFORMED IN 2012.
PROCESS USED TO ESTABLISH COMPENSATION FOR TOP MANAGEMENT OFFICIAL
FORM 990, PART VI, LINE 15A
ROCKFORD HEALTH PHYSICIANS' TOP MANAGEMENT OFFICIAL IS THE PRESIDENT & CEO OF ROCKFORD HEALTH SYSTEMS (RHS), THE SOLE CORPORATE MEMBER. COMPENSATION FOR EXECUTIVES, INCLUDING THE TOP MANAGEMENT OFFICIAL, IS GOVERNED BY THE RHS BOARD OF DIRECTORS. THE RHS BOARD HAS ESTABLISHED A TOTAL COMPENSATION PHILOSOPHY THAT DIRECTS THE COMPENSATION PRACTICES FOR ALL EXECUTIVES FROM ALL RELATED ENTITIES (INCLUDING RHPH). THIS BOARD HAS ESTABLISHED A COMPENSATION COMMITTEE TO ESTABLISH AND REVIEW ALL EXECUTIVE COMPENSATION ANNUALLY BASED ON THE ESTABLISHED PHILOSOPHY. AN INDEPENDENT EXTERNAL EXECUTIVE COMPENSATION FIRM PROVIDES CONSULTING ON RHS (INCLUDING RHPH) SALARY RANGES AND COMPENSATION PHILOSOPHY. THE APPROPRIATE PEER GROUP FOR COMPENSATION COMPARISON PURPOSES IS OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS SIMILAR IN SIZE AND COMPLEXITY. RHS GENERALLY CONDUCTS AN ANALYSIS OF TOTAL COMPENSATION EVERY THREE YEARS BUT MAY CHOOSE TO VARY FROM THIS SCHEDULE DETERMINED BY THE COMPENSATION COMMITTEE. THE RHPH BOARD OF DIRECTORS CONCEDES THE AUTHORITY TO SET COMPENSATION TO RHS.
Process used to establish compensation of other officers/key employees
Form 990, Part VI, Section B, Line 15b
COMPENSATION FOR EXECUTIVES, INCLUDING OTHER OFFICERS AND KEY EMPLOYEES, IS GOVERNED BY THE RHS BOARD OF DIRECTORS. THE RHS BOARD HAS ESTABLISHED A TOTAL COMPENSATION PHILOSOPHY THAT DIRECTS THE COMPENSATION PRACTICES FOR ALL EXECUTIVES FROM ALL RELATED ENTITIES (INCLUDING RHPH). THIS BOARD HAS ESTABLISHED A COMPENSATION COMMITTEE TO ESTABLISH AND REVIEW ALL EXECUTIVE COMPENSATION ANNUALLY BASED ON THE ESTABLISHED PHILOSOPHY. AN INDEPENDENT EXTERNAL EXECUTIVE COMPENSATION FIRM PROVIDES CONSULTING ON RHS (INCLUDING RHPH) SALARY RANGES AND COMPENSATION PHILOSOPHY. THE APPROPRIATE PEER GROUP FOR COMPENSATION COMPARISON PURPOSES IS OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS SIMILAR IN SIZE AND COMPLEXITY. RHS GENERALLY CONDUCTS AN ANALYSIS OF TOTAL COMPENSATION EVERY THREE YEARS BUT MAY CHOOSE TO VARY FROM THIS SCHEDULE DETERMINED BY THE COMPENSATION COMMITTEE. THE RHPH BOARD OF DIRECTORS CONCEDES THE AUTHORITY TO SET COMPENSATION TO RHS. THIS PROCESS WAS LAST COMPLETED IN 2012.
Governing documents, conflict of interest policy and financial statements available to the public
Form 990, Part VI, Section C, Line 19
FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ILLINOIS ATTORNEY GENERALS OFFICE. GOVERNING DOCUMENTS ARE AVAILABLE BY REQUEST FROM BOARD SECRETARY.
NONEMPLOYEE COMPENSATION
FORM 990, PART VII, SECTION A
CURTIS WORDEN IS NOT COMPENSATED AS A BOARD MEMBER; HE RECEIVED TAXABLE NONEMPLOYEE COMPENSATION ON A FORM 1099 FOR 2012 LEGAL SERVICES PROVIDED TO THE SYSTEM.
Other Expenses
Form 990, Part IX, Line 11g
OTHER EXPENSES - TOTAL EXPENSE: 416216, PROGRAM SERVICE EXPENSE: , MANAGEMENT AND GENERAL EXPENSES: 416216, FUNDRAISING EXPENSES: ; ADMINISTRATIVE FEE PAID TO RHS - TOTAL EXPENSE: 2230469, PROGRAM SERVICE EXPENSE: , MANAGEMENT AND GENERAL EXPENSES: 2230469, FUNDRAISING EXPENSES: ; OTHER PURCHASED SERVICES - TOTAL EXPENSE: 2751089, PROGRAM SERVICE EXPENSE: 1747506, MANAGEMENT AND GENERAL EXPENSES: 1003583, FUNDRAISING EXPENSES: ; BILLING AND COLLECTION AGENCY FEES - TOTAL EXPENSE: 4185229, PROGRAM SERVICE EXPENSE: , MANAGEMENT AND GENERAL EXPENSES: 4185229, FUNDRAISING EXPENSES: ; PURCHASED LABOR - TOTAL EXPENSE: 6647484, PROGRAM SERVICE EXPENSE: 6647484, MANAGEMENT AND GENERAL EXPENSES: , FUNDRAISING EXPENSES: ;
Other changes in net assets or fund balances
Form 990 , Part XI, Line 9
CUM EFF CHG IN ACCT - PENSION - -784155; CUM EFF CHG IN ACCT - POST RETIREMENT - -72053; TRANSFER FROM AFFILIATES - 52740173;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.