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
2011
Open to Public Inspection
Name of the organization
ALBANY AREA PRIMARY HEALTH CARE INC
Employer identification number
58-1344015
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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—2011.
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—2010.
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—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2011
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
2011
Open to Public Inspection
Name of the organization
ALBANY AREA PRIMARY HEALTH CARE INC
Employer identification number
58-1344015
Identifier
Return Reference
Explanation
ORGANIZATION'S MOST SIGNIFICANT ACTIVITIES
FORM 990, PART I, LINE 1
AS THE LARGEST PRIMARY CARE PHYSICIAN PRACTICE IN SOUTHWEST GEORGIA, ALBANY AREA PRIMARY HEALTH CARE PROVIDES HEALTH CARE SERVICES TO MORE THAN 36,000 PATIENTS IN BAKER, CALHOUN, DOOLY, DOUGHERTY, LEE AND TERRELL COUNTIES. OUR RURAL MODEL CLINIC, SPECIALIZING IN HIV MANAGEMENT, HAS EARNED NATIONAL RECOGNITION AND WE TAKE PRIDE IN OUR ACCREDITATION BY THE JOINT COMMISSION ON ACCREDITATION FOR HEALTHCARE ORGANIZATIONS.
ORGANIZATION'S MISSION
FORM 990, PART III, LINE 1
THE PURPOSES OF THIS CORPORATION ARE AS FOLLOWS: (A) TO MAKE HEALTH CARE DELIVERY AND ITS SUPPORTING ACTIVITIES A COMMON RESOURCE; (B) TO CARRY ON ANY EDUCATIONAL ACTIVITIES RELATED TO RENDERING CARE TO THE SICK AND INJURED, OR TO THE PROMOTION OF HEALTH, THAT IN THE OPINION OF THE BOARD OF DIRECTORS MAY BE JUSTIFIED BY THE FACILITIES, PERSONNEL, FUNDS, AND OTHER REQUIREMENTS THAT ARE, OR CAN BE, MADE AVAILABLE; (C) TO PARTICIPATE, SO FAR AS CIRCUMSTANCES MAY WARRANT, IN ANY ACTIVITY DESIGNED AND CARRIED ON TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY; (D) TO DEVELOP HEALTH SERVICES WHICH WILL MAKE QUALITY HEALTH CARE DELIVERY AVAILABLE, ACCESSIBLE AND ACCEPTABLE TO THE RESIDENTS OF THE AREAS SERVED; (E) TO PROVIDE PRIMARY HEALTH SERVICES, INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING: (1) DIAGNOSTIC, TREATMENT, CONSULTATIVE, REFERRAL AND OTHER SERVICES RENDERED BY PHYSICIANS, AND, WHERE FEASIBLE, BY PHYSICIANS, PHYSICIAN ASSISTANTS, NURSE CLINICIANS AND NURSE PRACTITIONERS; (2) DIAGNOSTIC LABORATORY SERVICES; AND (3) PREVENTIVE HEALTH SERVICES, INCLUDING CHILDREN EYE AND EAR EXAMINATIONS, PRENATAL AND POSTPARTUM CARE, PRENATAL SERVICES, WELL CHILD CARE, AND VOLUNTARY FAMILY PLANNING SERVICES; (F) TO COOPERATE AND COORDINATE WITH ORGANIZATIONS, AGENCIES, AND INSTITUTIONS, WHETHER THE SAME BE PUBLIC, PRIVATE OR GOVERNMENTAL, WHICH HAVE AS THEIR OBJECTIVE IMPROVEMENT OF HEALTH AND GENERAL WELFARE; (G) TO IMPROVE AND DISSEMINATE UPON RESIDENTS EDUCATIONAL INFORMATION PERTAINING TO GOOD HEALTH PRACTICES; AND (H) TO ENCOURAGE AND FOSTER THROUGH COMMUNITY EDUCATION THE IMPROVEMENT OF HEALTH CONDITIONS IN THE AREA.
FAMILY RELATIONSHIP
FORM 990, PART VI, SECTION A, LINE 2
BOARD MEMBERS MIRIAN WORTHY AND ROBERT MARSHALL HAVE A FAMILY RELATIONSHIP.
BOARD REVIEW OF FORM 990
FORM 990, PART VI, SECTION B, LINE 11B
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE CFO WILL REVIEW IN DETAIL WITH THE INDEPENDENT ACCOUNTING FIRM, THEN THE CFO WILL REVIEW WITH THE FINANCE COMMITTEE. A COPY OF THE 990 AND AN EXECUTIVE SUMMARY WILL BE PRESENTED TO THE FULL BOARD PRIOR TO THE RETURN BEING FILED.
CONFLICT OF INTEREST
FORM 990, PART VI, SECTION B, LINE 12C
THE ORGANIZATION REQUIRES WRITTEN DISCLOSURE CONFIRMATIONS TO BE SUBMITTED AND REVIEWED ANNUALLY WITH RESPECT TO CONFLICTS OF INTEREST. NO BOARD MEMBER MAY BE IN ANY MANNER INTERESTED, EITHER DIRECTLY OR INDIRECTLY, IN HIS OWN NAME OR ANY OTHER PERSON, ASSOCIATION, TRUST OR CORPORATION, IN ANY CONTRACT OR THE PERFORMANCE OF ANY WORK IN THE MAKING OR LETTING OF WHICH SUCH BOARD MEMBER MAY BE CALLED UPON TO ACT OR VOTE. NO SUCH BOARD MEMBER MAY REPRESENT EITHER AS AGENT OR OTHERWISE ANY PERSON, ASSOCIATION, TRUST, OR CORPORATION, WITH RESPECT TO ANY APPLICATION OR BID FOR ANY CONTRACT OR WORK IN REGARD TO WHICH SUCH BOARD MEMBER MAY BE CALLED UPON TO VOTE. NOR MAY ANY SUCH BOARD MEMBER TAKE OR RECEIVE, OR OFFER TO TAKE OR RECEIVE, EITHER DIRECTLY OR INDIRECTLY, ANY MONEY OR OTHER THING OF VALUE AS A GIFT OR BRIBE OR MEANS OF INFLUENCING HIS VOTE OR ACTION IN HIS OFFICIAL CHARACTER. ANY CONTRACT MADE AND PROCURED IN VIOLATION HEREOF IS VOID. IT IS ALSO RESOLVED THAT NO EMPLOYEE SHALL TAKE OR RECEIVE, OR OFFER TO TAKE OR RECEIVE, EITHER DIRECTLY OR INDIRECTLY, ANY MONEY OR OTHER THING OF VALUE AS A GIFT OR BRIBE OR MEANS OF INFLUENCING HIS ACTION IN HIS OFFICIAL CHARACTER AND THAT NO EMPLOYEE MAY BE IN ANY MANNER INTERESTED EITHER DIRECTLY OR INDIRECTLY IN HIS OWN NAME OR IN THE NAME OF ANY OTHER PERSON, ASSOCIATION, TRUST OR CORPORATION, IN ANY CONTRACT OR THE PERFORMANCE OF ANY WORK IN THE MAKING OR LETTING OF WHICH SUCH EMPLOYEE MAY BE CALLED UPON TO ACT. VIOLATION OF THIS RESOLUTION BY ANY EMPLOYEE WILL RESULT IN THE TERMINATION OF SAID PARTY'S EMPLOYMENT BY AAPHC.
PROCESS FOR DETERMINING COMPENSATION
FORM 990, PART VI, SECTION B, LINES 15A & 15B
SALARY SURVEYS FROM NACHC, MGMA, AND OTHER ONLINE RESOURCES ARE EVALUATED FOR ALL KEY POSITIONS ANNUALLY BY THE CEO AND THE DEPUTY DIRECTOR. IF THERE IS A RECOMMENDATION THE PAY SCALE BE ADJUSTED TO FALL WITHIN THE RANGE SET BY THE MARKET, THE RECOMMENDATION IS TAKEN BEFORE THE BOARD. THE BOARD DOES NOT APPROVE THE PAY SCALE ANNUALLY, ONLY WHEN ADJUSTMENTS ARE MADE. THE BOARD DOCUMENTS THE REVIEW AND APPROVAL OF ALL ADJUSTMENTS. THE CEO SALARY WAS REVIEWED AND TAKEN BEFORE THE BOARD IN JULY 2011. AFTER THE MEETING, THE BOARD HELD AN EXECUTIVE SESSION WHERE THEY APPROVED THE ADJUSTMENT OF THE CEO PAY SCALE. THE PROCESS IS DOCUMENTED IN THE PERSONNEL COMMITTEE MEETING MINUTES.
DOCUMENT DISCLOSURE
FORM 990, PART VI, SECTION C, LINE 19
GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS WILL BE MADE AVAILABLE FOR VIEWING ON-SITE UPON REQUEST.
OTHER CHANGES IN NET ASSETS
FORM 990, PART XI, LINE 5
350 UNREALIZED GAIN
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.