Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
WELLMONT MEDICAL ASSOCIATES INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1905 AMERICAN WAY
 
Room/suite
City or town, state or country, and ZIP + 4
KINGSPORT, TN37660
D Employer identification number

27-0898372
E Telephone number

G Gross receipts $ 13,639,409
F Name and address of principal officer:
TODD J DOUGAN
1905 AMERICAN WAY
KINGSPORT,TN37660
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.WELLMONT.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 2008
M State of legal domicile: TN
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 17
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 0
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 68
6 Total number of volunteers (estimate if necessary) .... 6  
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) .........   0
9 Program service revenue (Part VIII, line 2g) ......... 2,503,832 13,233,620
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....   0
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 157,259 405,789
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 2,661,091 13,639,409
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...   0
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 2,447,275 9,425,791
16a Professional fundraising fees (Part IX, column (A), line 11e).....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 461,741 6,284,406
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 2,909,016 15,710,197
19 Revenue less expenses. Subtract line 18 from line 12....... -247,925 -2,070,788
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 7,085 1,144,761
21 Total liabilities (Part X, line 26)............. 255,010 1,305,578
22 Net assets or fund balances. Subtract line 21 from line 20..... -247,925 -160,817
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 13,362,715 including grants of $   ) (Revenue $ 13,594,208 )
WELLMONT MEDICAL ASSOCIATES, INC. IS PHYSICIAN-LED AND PROFESSIONALLY MANAGED. FROM ITS BOARD OF DIRECTORS AND LEADERSHIP TEAM MEMBERS TO THE PROVIDERS WHO CARE FOR PATIENTS EVERY DAY, WELLMONT MEDICAL ASSOCIATES, INC.'S COMMITMENT TO PHYSICIAN LEADERSHIP IS CLEAR. WELLMONT MEDICAL ASSOCIATES, INC., A NON-PROFIT HEALTHCARE PROVIDER, DELIVERS EXCEPTIONAL CARE TO PATIENTS IN THE TRI-CITIES REGION OF NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA. BASED IN KINGSPORT, TENNESSEE, AS WELL AS LOCATIONS EXPANDING FROM SNEEDVILLE, TENNESSEE, TO MARION, VIRGINIA, WELLMONT MEDICAL ASSOCIATES, INC. OFFERS THE LATEST IN TECHNOLOGICAL ADVANCES TO ENSURE PATIENTS RECEIVE SUPERIOR CARE. WE ARE DEDICATED TO IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. IN FISCAL YEAR 2012, WE EXPANDED OUR SERVICES TO INCLUDE OFFICES IN JOHNSON CITY, TENNESSEE, AS WELL AS BOLSTERED CARE IN RURAL AREAS OF VIRGINIA. IN FISCAL YEAR 2012, WE HAD 25,119 OFFICE VISITS AND 16,318 HOSPITAL/NURSING HOME VISITS. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT MEDICAL ASSOCIATES, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING THAT SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS INCURRING COSTS OF 59,924. ADDITIONALLY, WE PROVIDED CARE TO PERSONS COVERED BY MEDICARE, MEDICAID, TENNCARE AND CHAMPUS AT LESS THAN COST. DUE TO MANDATED REDUCTIONS IN MEDICARE FUNDING FROM THE BALANCED BUDGET ACT AND DECLINING REIMBURSEMENT FROM TENNCARE, THE SHORTFALL BETWEEN RECEIPTS AND THE COST OF PROVIDING CARE TO THESE PATIENTS TOTALED 18,125,650. OTHER COMMUNITY ACTIVITIES TOTALED 11,568. OVERALL, WE RETURNED MORE THAN 18,197,142 IN BENEFITS TO OUR REGION. IT IS OUR OBLIGATION TO SUPPORT THE CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. WE SPONSORED EDUCATIONAL, COMMUNITY-BASED PROGRAMS ON HEALTHY LIFESTYLES, RISK FACTOR IDENTIFICATION AND OPTIONS FOR DIAGNOSIS AND TREATMENT. PROGRAMS INCLUDED: - LECTURES ABOUT ASTHMA TO AREA ELEMENTARY SCHOOLS - WORKING WITH FRIENDS IN NEED, WHICH PROVIDES ON-SITE PRIMARY CARE - PROVIDING FREE MEDICAL CARE THROUGH REMOTE AREA MEDICAL CLINIC - WORKING WITH APPALACHIAN MOUNTAIN PROJECT ACCESS - TEACHING AT LINCOLN MEMORIAL UNIVERSITY-DEBUSK COLLEGE OF OSTEOPATHIC MEDICINE - TEACHING AT UNIVERSITY OF VIRGINIA'S COLLEGE AT WISE - PROVIDING A FREE CLINIC IN CHURCH HILL, TENNESSEE - THE HEALTH WAGON IN CLINTWOOD, VIRGINIA WE ALSO PARTICIPATED IN A NUMBER OF HEALTH FAIRS AND COMMUNITY SCREENINGS. EMPLOYEES GAVE THEIR TIME TO AREA NONPROFIT ORGANIZATIONS, WHICH INCLUDED THE UNITED WAY AND THE TRI-CITIES AFFILIATE OF SUSAN G. KOMEN FOR THE CURE. THEY ALSO DONATED AS PART OF WELLMONT'S EMPLOYEE GIVING CAMPAIGN TO FUNDS SUCH AS THE WELLMONT CANCER INSTITUTE PATIENT ASSISTANCE FUND, EMPLOYEE EMERGENCY FUND AND MANY OTHERS.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 13,362,715
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? ........
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
 
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
13
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
68
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
17
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
0
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
Yes
 
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
TN
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
TODD J DOUGAN
1905 AMERICAN WAY
KINGSPORT,TN37660
(423) 230-8512
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) MARGARET DENARVAEZ
WHS PRESIDEN
 1.00 X   X       0 968,330 19,800
(2) ELIZABETH WARD THROUGH 110611
FORMER PRES.
 0.00 X   X       0 927,837 8,596
(3) ANILKUMAR TUMKUR MD
DIRECTOR
 40.00 X           505,526 0 21,214
(4) JAMES BECKNER MD
DIRECTOR
 40.00 X           466,403 0 31,188
(5) MARISSA VITO CRUZ MD
DIRECTOR
 40.00 X           437,480 0 30,049
(6) JASON BRAZEE MD
CHIEF ADM ME
 40.00 X   X       430,711 0 34,363
(7) MAURICE NIDA DO
DIRECTOR
 40.00 X           421,088 0 24,736
(8) DAVID THOMPSON MD
CHAIR
 40.00 X   X       395,810 0 9,484
(9) JOHN HOWARD
WMA PRESIDEN
 20.00 X   X       0 358,746 8,905
(10) JOSEPH SMIDDY MD
VICE CHAIR
 40.00 X   X       336,581 0 10,470
(11) LANDON COMBS MD
SECRETARY
 40.00 X   X       259,792 0 23,969
(12) LENITA THIBAULT MD
DIRECTOR
 40.00 X           248,837 0 16,083
(13) STEPHEN COMBS MD
CHIEF EXEC M
 40.00 X   X       209,382 0 17,331
(14) KIMBERLY ROLLER MD
DIRECTOR
 40.00 X           188,801 0 10,680
(15) DAVID ASTIN MD
DIRECTOR
 40.00 X           169,323 0 19,285
(16) AMANDA DOVE MD
DIRECTOR, WE
 40.00 X           74,356 0 1,235
(17) SUE PRILL MD010112 TO PRESENT
DIRECTOR
 40.00 X           0 0 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) KIM ONESKO 061812 TO PRESENT
CHIEF ADMIN
 40.00 X   X       0 0 0
(19) BRUCE GROVER MD
PHYSICIAN
 40.00         X   475,047 0 31,554
(20) ROBERT ROSSER MD
PHYSICIAN
 40.00         X   430,803 0 30,083
(21) MARK EMERY MD
PHYSICIAN
 40.00         X   316,273 0 11,910
(22) LUCINDA MILLER MD
PHYSICIAN
 40.00         X   291,501 0 0
(23) MAYUR PATEL MD
PHYSICIAN
 40.00         X   282,464 0 11,281














1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 5,940,178 2,254,913 372,216
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet8
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet  
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet  
Program Service Revenue Business Code
2a PATIENT SERVICE REVENUE-NET 621,990 12,798,094 12,798,094    
b ON-CALL SERVICES REVENUE 621,990 225,000 225,000    
c DIAGNOSTIC INTERPRETATIONS 621,990 140,810 140,810    
d RESEARCH REVENUE 541,700 69,716 69,716    
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 13,233,620
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet        
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross rents 45,201  
b Less: rental expenses    
c Rental income or (loss) 45,201  
d Net rental income or (loss).......MediumBullet 45,201     45,201
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss)    
d Net gain or (loss)..........MediumBullet        
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a MEDICAL DIRECTORSHIP 621,990 322,833 322,833    
b CONTRACT SERVICES 621,990 31,500 31,500    
c TRAINING REVENUE 611,710 6,255 6,255    
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 360,588
12 Total revenue. See Instructions....MediumBullet 13,639,409 13,594,208   45,201
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21    
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 5,162,267 4,466,040 696,227  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 3,544,563 3,124,853 419,710  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 34,256 14,551 19,705  
9 Other employee benefits ....... 244,465 237,326 7,139  
10 Payroll taxes ........... 440,240 427,724 12,516  
11 Fees for services (non-employees):        
a Management ...... 73,383 16,716 56,667  
b Legal ......... 91   91  
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 167,235 154,354 12,881  
12 Advertising and promotion .... 38,705 35,831 2,874  
13 Office expenses ....... 178,405 149,084 29,321  
14 Information technology ......        
15 Royalties ..        
16 Occupancy ........... 546,055 539,746 6,309  
17 Travel ............ 39,056 38,152 904  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ........... 82,312   82,312  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 261,419 235,277 26,142  
23 Insurance .............. 72,616 72,616    
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a DRUGS & MEDICAL SUPPLIES 3,538,262 3,538,262    
b MANAGEMENT SERVICES AGMT 973,088   973,088  
c PROVISION FOR BAD DEBTS 187,995 187,995    
d DUES AND MEMBERSHIPS 67,563 67,104 459  
e
f All other expenses 58,221 57,084 1,137  
25 Total functional expenses. Add lines 1 through 24f 15,710,197 13,362,715 2,347,482 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... -289 1 5,114
2 Savings and temporary cash investments .......   2  
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... -1,473,502 4 -4,158,978
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7 138,020
8 Inventories for sale or use .............. 24,700 8 155,078
9 Prepaid expenses and deferred charges ............   9 80,167
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 3,968,697
b Less: accumulated depreciation. ..... 10b 289,656 209,857 10c 3,679,041
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 ......   12  
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets ......... 1,246,319 14 1,246,319
15 Other assets. See Part IV, line 11 ...........   15  
16 Total assets. Add lines 1 through 15 (must equal line 34)... 7,085 16 1,144,761
Liabilities 17 Accounts payable and accrued expenses . 231,111 17 1,276,770
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 23,899 25 28,808
26 Total liabilities. Add lines 17 through 25..... 255,010 26 1,305,578
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... -247,925 27 -160,817
28 Temporarily restricted net assets .....   28  
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... -247,925 33 -160,817
34 Total liabilities and net assets/fund balances ..... 7,085 34 1,144,761
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
13,639,409
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
15,710,197
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
-2,070,788
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
-247,925
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
2,157,896
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
-160,817
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
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
f
g
(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
(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
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
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......       2,503,832 13,233,620 15,737,452
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.       2,503,832 13,233,620 15,737,452
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.)           15,737,452
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...       2,503,832 13,233,620 15,737,452
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..       3,759 45,201 48,960
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.       3,759 45,201 48,960
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.)       153,500 360,588 514,088
13 Total support (Add lines 9, 10c, 11 and 12.).       2,661,091 13,639,409 16,300,500
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
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
WELLMONT MEDICAL ASSOCIATES, INC. BEGAN OPERATIONS ON 01/01/11. WHEN THE LEGAL COUNSEL FOR WELLMONT MEDICAL ASSOCIATES, INC. FILED FORM 1023, APPLICATION FOR RECOGNITION OF EXEMPTION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, PART X, PUBLIC CHARITY STATUS, LINE G - (509(A)(1) AND 170(B)(1)(A)(VI) - AN ORGANIZATION THAT RECEIVES A SUBSTANTIAL PART OF ITS FINANCIAL SUPPORT IN THE FORM OF CONTRIBUTIONS FROM PUBLICLY SUPPORTED ORGANIZATIONS, FROM A GOVERNMENTAL UNIT, OR FROM THE GENERAL PUBLIC WAS MISTAKENLY CHECKED. ON APRIL 18, 2011, THE IRS GRANTED WELLMONT MEDICAL ASSOCIATES, INC. EXEMPTION UNDER THIS CODE SECTION. THE INITIAL RETURN FOR THE SIX MONTHS ENDED JUNE 30, 2011 WAS FILED UNDER THIS CODE SECTION FOR SCHEDULE A, PUBLIC CHARITY STATUS AND PUBLIC SUPPORT FOR BOTH PART I AND PART II. WELLMONT MEDICAL ASSOCIATES, INC. OPERATIONS HAVE IN FACT BEEN UNDER LINE H - 509(A)(2) - AN ORGANIZATION THAT NORMALLY RECEIVES NOT MORE THAN ONE-THIRD OF ITS FINANCIAL SUPPORT FROM GROSS INVESTMENT INCOME AND RECEIVES MORE THAN ONE-THIRD OF ITS SUPPORT FROM CONTRIBUTIONS, MEMBERSHIP FEES, AND GROSS RECEIPTS FROM ACTIVITIES RELATED TO ITS EXEMPT FUNCTIONS. FOR THE YEAR ENDED JUNE 30, 2012, WELLMONT MEDICAL ASSOCIATES, INC. HAS PROPERLY REPORTED SCHEDULE A, LINE 9 AND COMPLETED SCHEDULE A, PART III.
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


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SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....        
b Contributions ........        
c Net investment earnings, gains, and losses ...        
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....        
g End of year balance ......        
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
No
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................   3,311,661 174,716 3,136,945
c Leasehold improvements ............        
d Equipment ................   587,914 103,842 484,072
e Other .................   69,122 11,098 58,024
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 3,679,041
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes  
INSURANCE L/T LIABILITY 17,064
CAPITAL LEASE OBLIGATION 11,744







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 28,808
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
LIABILITY UNDER FIN 48 FOOTNOTE SCHEDULE D, PAGE 3, PART X THE WELLMONT HEALTH SYSTEM ENTITIES ARE PRIMARILY CLASSIFIED AS ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(A) AS ENTITIES DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN INCLUDED FOR THESE ENTITIES IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE OPERATIONS OF WELLMONT HEALTH SYSTEM ARE SUBJECT TO STATE AND FEDERAL INCOME TAXES WHICH ARE ACCOUNTED FOR IN ACCORDANCE WITH ASC 740, INCOME TAXES; HOWEVER, SUCH AMOUNTS ARE NOT MATERIAL.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
Yes
 
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) MARGARET DENARVAEZ (i)
(ii)		  
721,998 		 
231,000 		 
15,332 		 
14,126 		 
5,674 		 
988,130 		 
 
(2) ELIZABETH WARD THROUGH 110611 (i)
(ii)		  
384,808 		 
107,663 		 
435,366 		 
  		 
8,596 		 
936,433 		 
 
(3) ANILKUMAR TUMKUR MD (i)
(ii)		 353,485
  		151,861
  		180
  		11,644
  		9,570
  		526,740
  		 
 
(4) JAMES BECKNER MD (i)
(ii)		 404,332
  		20,881
  		41,190
  		21,364
  		9,824
  		497,591
  		 
 
(5) MARISSA VITO CRUZ MD (i)
(ii)		 201,484
  		25,000
  		210,996
  		20,318
  		9,731
  		467,529
  		 
 
(6) JASON BRAZEE MD (i)
(ii)		 340,403
  		39,672
  		50,636
  		22,711
  		11,652
  		465,074
  		 
 
(7) MAURICE NIDA DO (i)
(ii)		 225,417
  		20,283
  		175,388
  		16,897
  		7,839
  		445,824
  		 
 
(8) DAVID THOMPSON MD (i)
(ii)		 255,776
  		94,572
  		45,462
  		 
  		9,484
  		405,294
  		 
 
(9) JOHN HOWARD (i)
(ii)		  
268,284 		 
38,672 		 
51,790 		 
  		 
8,905 		 
367,651 		 
 
(10) JOSEPH SMIDDY MD (i)
(ii)		 334,383
  		 
  		2,198
  		 
  		10,470
  		347,051
  		 
 
(11) LANDON COMBS MD (i)
(ii)		 191,510
  		26,130
  		42,152
  		14,145
  		9,824
  		283,761
  		 
 
(12) LENITA THIBAULT MD (i)
(ii)		 217,568
  		29,706
  		1,563
  		13,116
  		2,967
  		264,920
  		 
 
(13) STEPHEN COMBS MD (i)
(ii)		 205,438
  		318
  		3,626
  		11,558
  		5,773
  		226,713
  		 
 
(14) KIMBERLY ROLLER MD (i)
(ii)		 174,467
  		8,740
  		5,594
  		10,680
  		 
  		199,481
  		 
 
(15) DAVID ASTIN MD (i)
(ii)		 134,912
  		33,843
  		568
  		8,129
  		11,156
  		188,608
  		 
 
(16) BRUCE GROVER MD (i)
(ii)		 472,240
  		 
  		2,807
  		24,459
  		7,095
  		506,601
  		 
 
(17) ROBERT ROSSER MD (i)
(ii)		 429,661
  		 
  		1,142
  		22,988
  		7,095
  		460,886
  		 
 
(18) MARK EMERY MD (i)
(ii)		 315,875
  		 
  		398
  		 
  		11,910
  		328,183
  		 
 
(19) LUCINDA MILLER MD (i)
(ii)		 291,328
  		 
  		173
  		 
  		 
  		291,501
  		 
 
(20) MAYUR PATEL MD (i)
(ii)		 282,308
  		 
  		156
  		 
  		11,281
  		293,745
  		 
 
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
FRINGE OR EXPENSE EXPLANATION SCHEDULE J, PAGE 1, PART I, LINE 1A CHARTER TRAVEL AND TRAVEL FOR COMPANIONS WELLMONT HEALTH SYSTEM PROVIDED AIRPLANE TRAVEL FOR ITS EXECUTIVES THROUGH A PARTIAL OWNERSHIP OF AN AIRPLANE. ON OCCASION, TRAVEL WAS PROVIDED FOR EXECUTIVES AND THEIR COMPANIONS FOR PERSONAL USE. WELLMONT HEALTH SYSTEM FOLLOWED IRS GUIDELINES AND INCLUDED THE APPROPRIATE AMOUNTS IN THEIR TAXABLE COMPENSATION. HOUSING ALLOWANCE WELLMONT HEALTH SYSTEM OFFERED A HOUSING ALLOWANCE FOR JOHN HOWARD, VP OF LEGAL AFFAIRS, DURING THE FISCAL YEAR ENDED JUNE 30, 2012. THE HOUSING ALLOWANCES PAID TO THE EXECUTIVE WAS INCLUDED IN HIS TAXABLE COMPENSATION. HEALTH OR SOCIAL CLUB DUES DURING THE FISCAL YEAR ENDED JUNE 30, 2012, WELLMONT HEALTH SYSTEM PROVIDED COUNTRY CLUB MEMBERSHIPS TO MARGARET DENARVAREZ AND JOHN HOWARD. THESE AMOUNTS ARE INCLUDED IN THEIR TAXABLE COMPENSATION.
RELATED ORG METHODS USED FOR COMPENSATION EXPLANATION SCHEDULE J, PAGE 1, PART I, LINE 3 WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF ALL PERSONS LISTED ON FORM 990, PART VII, SECTION A AS MORE FULLY DESCRIBED IN SCHEDULE O.
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SCHEDULE J, PAGE 1, PART I, LINE 4 ELIZABETH WARD (THROUGH 11/06/11) 435,000 0 0
COMPENSATION CONTINGENT UPON NET EARNINGS OF RELATED ORG SCHEDULE J, PAGE 1, PART I, LINE 6B INCENTIVE COMPENSATION IS BASED ON MEETING BUDGETED OPERATING MARGIN GOALS.
OTHER ADDITIONAL INFORMATION SCHEDULE J, PART III WELLMONT HEALTH SYSTEM HAS AN EXECUTIVE RETIREMENT PROGRAM THAT INCLUDED MARGARET DENARVAEZ, ELIZABETH WARD, AND JOHN HOWARD FOR THE FISCAL YEAR ENDING JUNE 30, 2012. THIS PROGRAM HAS A TARGET BENEFIT OF 60% OF THE HIGHEST THREE YEAR AVERAGE SALARY (LESS EMPLOYER PROVIDER BENEFITS) AND THE EXECUTIVE MUST HAVE TWENTY YEARS OF SERVICE TO RECEIVE THE FULL BENEFIT. THE EXECUTIVE MAY RETIRE EARLY AT AGE 60 AND RECEIVE REDUCED BENEFITS. THERE WERE NO PAYMENTS MADE UNDER THIS PROGRAM FOR THE FISCAL YEAR ENDING JUNE 30, 2012.
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) THE HEART CENTER PARTNERSHIP
  		BOARD OVERLAP 109,560 LEASE AGREEMENT   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
ADDITIONAL INFORMATION SCHEDULE L PART V WELLMONT MEDICAL ASSOCIATES LESSEE ENTERED INTO A LEASE AGREEMENT WITH THE HEART CENTER PARTNERSHIP LESSOR ON JUNE 01 2010 TO LEASE 4205 RENTABLE SQUARE FEET ON THE SECOND FLOOR IN THE BUILDING KNOWN AS THE HEART CENTER LOCATED AT 2050 MEADOWVIEW PARKWAY KINGSPORT TENNESSEE 37660 FOR A FIVE YEAR TERM WITH A RENEWAL OPTION OF ONE ADDITIONAL TERM OF FIVE YEARS IF LESSEE DESIRES TO EXERCISE ITS RIGHT TO RENEW LESSEE MUST NOTIFY THE LANDLORD WITH A SIX MONTH WRITTEN NOTICE THERE ARE CURRENTLY 33 PHYSICIANS EMPLOYED BY WELLMONT CARDIOLOGY SERVICES OF WHICH 29 ARE SENIOR PHYSICIANS THE 29 SENIOR PHYSICIANS ARE THE CURRENT PARTNERS OF THE HEART CENTER PARTNERSHIP THE HEART CENTER PARTNERSHIP IS NOT OWNED BY WELLMONT HEALTH SYSTEM WELLMONT CARDIOLOGY SERVICES WHICH IS ALSO A SUBSIDIARY OF WELLMONT HEALTH SYSTEM WHO IS THE SOLE MEMBER OF THE CORPORATION OR ANY AFFILIATED ENTITIES THE 29 PHYSICIANS MENTIONED IN THE LEASE AGREEMENT ARE AS FOLLOWS DAVID C BECKNER MD JOHN F BERRY MD JOHN R BERTUSO MD GERALD G BLACKWELL MD MARK A BORSCH MD THOMAS M BULLE MD JONATHAN W BURRESS MD LARRY H COX MD ANDREW M CROSS JR MD STANLEY A GALL JR MD DAVID TYLER GREENFIELD MD CLAIR S HIXSON MD PIERRE ISTFAN MD GREGORY K JONES MD CHRISTOPHER J KENNEDY MD ROBERT KEITH KRAMER MD HERBERT D LADLEY MD MARC W MAYHEW MD JAMES J MERRILL MD WILLIAM M MESSERSCHMIDT MD DAVID CHRISTOPHER METZGER MD CARY H MEYERS MD DANIEL M OROARK MD ARUN RAO MD PABITRA K SAHA MD DANIEL E SIMPSON MD HARRISON D TURNER MD FREDDIE M WILLIAMS MD MARCUS WILLIAMS MD
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
Identifier Return Reference Explanation
FIRST ACCOMPLISHMENT DESCRIPTION FORM 990, PAGE 2, PART III, LINE 4A WE ARE DEDICATED TO IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. IN FISCAL YEAR 2012, WE EXPANDED OUR SERVICES TO INCLUDE OFFICES IN JOHNSON CITY, TENNESSEE, AS WELL AS BOLSTERED CARE IN RURAL AREAS OF VIRGINIA. IN FISCAL YEAR 2012, WE HAD 25,119 OFFICE VISITS AND 16,318 HOSPITAL/NURSING HOME VISITS. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT MEDICAL ASSOCIATES, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING THAT SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS INCURRING COSTS OF 59,924. ADDITIONALLY, WE PROVIDED CARE TO PERSONS COVERED BY MEDICARE, MEDICAID, TENNCARE AND CHAMPUS AT LESS THAN COST. DUE TO MANDATED REDUCTIONS IN MEDICARE FUNDING FROM THE BALANCED BUDGET ACT AND DECLINING REIMBURSEMENT FROM TENNCARE, THE SHORTFALL BETWEEN RECEIPTS AND THE COST OF PROVIDING CARE TO THESE PATIENTS TOTALED 18,125,650. OTHER COMMUNITY ACTIVITIES TOTALED 11,568. OVERALL, WE RETURNED MORE THAN 18,197,142 IN BENEFITS TO OUR REGION. IT IS OUR OBLIGATION TO SUPPORT THE CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. WE SPONSORED EDUCATIONAL, COMMUNITY-BASED PROGRAMS ON HEALTHY LIFESTYLES, RISK FACTOR IDENTIFICATION AND OPTIONS FOR DIAGNOSIS AND TREATMENT. PROGRAMS INCLUDED: - LECTURES ABOUT ASTHMA TO AREA ELEMENTARY SCHOOLS - WORKING WITH FRIENDS IN NEED, WHICH PROVIDES ON-SITE PRIMARY CARE - PROVIDING FREE MEDICAL CARE THROUGH REMOTE AREA MEDICAL CLINIC - WORKING WITH APPALACHIAN MOUNTAIN PROJECT ACCESS - TEACHING AT LINCOLN MEMORIAL UNIVERSITY-DEBUSK COLLEGE OF OSTEOPATHIC MEDICINE - TEACHING AT UNIVERSITY OF VIRGINIA'S COLLEGE AT WISE - PROVIDING A FREE CLINIC IN CHURCH HILL, TENNESSEE - THE HEALTH WAGON IN CLINTWOOD, VIRGINIA WE ALSO PARTICIPATED IN A NUMBER OF HEALTH FAIRS AND COMMUNITY SCREENINGS. EMPLOYEES GAVE THEIR TIME TO AREA NONPROFIT ORGANIZATIONS, WHICH INCLUDED THE UNITED WAY AND THE TRI-CITIES AFFILIATE OF SUSAN G. KOMEN FOR THE CURE. THEY ALSO DONATED AS PART OF WELLMONT'S EMPLOYEE GIVING CAMPAIGN TO FUNDS SUCH AS THE WELLMONT CANCER INSTITUTE PATIENT ASSISTANCE FUND, EMPLOYEE EMERGENCY FUND AND MANY OTHERS.
CLASSES OF MEMBERS OR STOCKHOLDERS FORM 990, PAGE 6, PART VI, LINE 6 THE BUSINESS AND AFFAIRS OF WELLMONT MEDICAL ASSOCIATES, INC. (THE CORPORATION) SHALL BE GOVERNED EXCLUSIVELY BY THE BOARD OF DIRECTORS. THE CORPORATION'S BOARD OF DIRECTORS IS DESIGNATED BY WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION. IN ADDITION TO SUCH RIGHTS OF APPROVAL AND CONSENT AS MAY BE RESERVED TO THE SOLE MEMBER OF THE CORPORATION PURSUANT TO APPLICABLE LAW, TRANSACTIONS OF THE FOLLOWING MATTERS BY THE CORPORATION SHALL REQUIRE THE PRIOR APPROVAL OF WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION: (A) IMPLEMENTATION OF CORPORATION'S ANNUAL BUDGET, (B) INCURRING ANY LOAN OR OTHER INDEBTEDNESS FOR BORROWED MONEY, (C) ACQUISITION OF ANY EQUIPMENT OR PERSONAL PROPERTY FOR A PURCHASE PRICE IN EXCESS OF 50,000 OR THE ACQUISITION OF ANY REAL ESTATE, REGARDLESS OF PURCHASE PRICE, (D) THE UNDERTAKING OF CERTAIN CONTRACTUAL COMMITMENTS, (E) ENTERING INTO ANY PLAN OF MERGER OR CONSOLIDATION, (F) ACQUISITION OF SUBSTANTIALLY ALL OF THE ASSETS OF ANY OTHER LEGAL ENTITY, AND (G) INSTITUTION OF ANY LITIGATION BY OR ON BEHALF OF CORPORATION.
ELECTION OF MEMBERS AND THEIR RIGHTS FORM 990, PAGE 6, PART VI, LINE 7A SEE FORM 990, PART VI, SECTION A, LINE 6 EXPLANATION.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS FORM 990, PAGE 6, PART VI, LINE 7B SEE FORM 990, PART VI, SECTION A, LINE 6 EXPLANATION.
OFFICERS WHO CANNOT BE REACHED FORM 990, PAGE 6, PART VI, LINE 9 ELIZABETH WARD (THROUGH 11/06/11)
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, LINE 11B WELLMONT MEDICAL ASSOCIATES, INC.'S FORM 990 IS REVIEWED BY THE SENIOR VICE PRESIDENT OF FINANCE, THE CORPORATE CONTROLLER, AND THE MANAGER OF ACCOUNTING OF WELLMONT HEALTH SYSTEM, AND THE BOARD OF DIRECTORS OF WELLMONT MEDICAL ASSOCIATES, INC. PRIOR TO FILING. ANY QUESTIONS OR COMMENTS ARISING FROM THE INITIAL REVIEW ARE ADDRESSED TO ENSURE THE RETURN IS COMPLETE AND ACCURATE. ANY CHANGES OR CORRECTIONS ARE IDENTIFIED, REVISED IN THE RETURN, AND REVIEWED BY THE INDIVIDUALS LISTED ABOVE PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE.
ENFORCEMENT OF CONFLICTS POLICY FORM 990, PAGE 6, PART VI, LINE 12C OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT. ANY POTENTIAL CONFLICTS ARE DISCUSSED WITH THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, AS THEY ARISE. WELLMONT MEDICAL ASSOCIATES, INC.'S OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE GOVERNED BY WELLMONT HEALTH SYSTEM'S CONFLICT OF INTEREST POLICY. WELLMONT HEALTH SYSTEM ALSO HAS A POLICY ON BUSINESS PRACTICES THAT DISCUSSES CONFLICT OF INTEREST AND INFORMS THE WORKFORCE TO DISCLOSE ANY ISSUES TO THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, FOR RESOLUTION. WELLMONT HEALTH SYSTEM ALSO USES A HOTLINE THAT ALLOWS ANONYMOUS REPORTING OF POSSIBLE CONFLICT OF INTEREST SITUATIONS FOR INVESTIGATION BY THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT.
COMPENSATION PROCESS FOR TOP OFFICIAL FORM 990, PAGE 6, PART VI, LINE 15A THE COMPENSATION OF MARGARET DENARVAEZ, THE PRESIDENT AND CEO OF WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND BOARD OF DIRECTORS. MARGARET DENARVAEZ IS ALSO THE CHAIR OF WELLMONT MEDICAL ASSOCIATES, INC. THE COMPENSATION OF ELIZABETH WARD, THE FORMER EXECUTIVE VICE-PRESIDENT AND CHIEF FINANCIAL OFFICER OF WELLMONT HEALTH SYSTEM (THROUGH 11/06/11), WAS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND BOARD OF DIRECTORS. ELIZABETH WARD WAS ALSO THE FORMER PRESIDENT OF WELLMONT MEDICAL ASSOCIATES, INC. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THE LAST COMPENSATION DELIBERATION AND REVIEW PROCESS FOR MARGARET DENARVAEZ AND ELIZABETH WARD WAS COMPLETED ON MARCH 15, 2011.
COMPENSATION PROCESS FOR OFFICERS FORM 990, PAGE 6, PART VI, LINE 15B THE COMPENSATION OF JOHN HOWARD, THE PRESIDENT AND CEO OF WELLMONT MEDICAL ASSOCIATES, INC. AND GENERAL COUNSEL FOR WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND BOARD OF DIRECTORS. JOHN HOWARD IS ALSO A BOARD MEMBER OF WELLMONT CARDIOLOGY SERVICES AND THE SECRETARY FOR WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. WELLMONT MEDICAL ASSOCIATES, INC. USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF STEPHEN COMBS, M.D., CHIEF EXECUTIVE MEDICAL OFFICER, KIM ONESKO, CHIEF ADMINISTRATIVE OFFICER, JASON BRAZEE, M.D., CHIEF ADMINISTRATIVE MEDICAL OFFICER. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IS COMPLETED ON AN ANNUAL BASIS. THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS REVIEWED THE SALARY AND MARKET COMPENSATION DATA FOR JOHN HOWARD ON NOVEMBER 17, 2011.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 19 WELLMONT MEDICAL ASSOCIATES, INC.'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. WELLMONT HEALTH SYSTEM'S AUDITED FINANCIAL STATEMENTS AND QUARTERLY UNAUDITED FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ELECTRONIC MUNICIPAL MARKET ACCESS WEBSITE.
OTHER CHANGES IN NET ASSETS EXPLANATION FORM 990, PART XI, LINE 5 INTERCOMPANY RESOLUTION 2,157,896 ==========
CHANGE IN FINANCIAL REVIEW PROCESS FORM 990, PAGE 12, PART XII, LINE 2C WELLMONT MEDICAL ASSOCIATES, INC.'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF WELLMONT HEALTH SYSTEM. WELLMONT MEDICAL ASSOCIATES, INC.'S FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2012 WERE AUDITED AS PART OF WELLMONT HEALTH SYSTEM'S CONSOLIDATED FINANCIAL STATEMENTS. WELLMONT HEALTH SYSTEM HAS AN AUDIT COMMITTEE WHICH ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT AUDITOR. THIS REVIEW PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
WELLMONT MEDICAL ASSOCIATES INC
 
Employer identification number

27-0898372
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) WELLMONT HEALTH SYSTEM

1905 AMERICAN WAY

KINGSPORT,TN37660
62-1636465 		HEALTHCARE TN 501C3 3 NA
 
 
No
(2) WELLMONT MADISON HOUSE

1905 AMERICAN WAY

KINGSPORT,TN37660
62-1308216 		HEALTHCARE TN 501C3 9 WHS
 
 
No
(3) WELLMONT FOUNDATION INC

1905 AMERICAN WAY

KINGSPORT,TN37660
58-1594191 		HEALTHCARE TN 501C3 7 WHS
 
 
No
(4) WELLMONT IMAGING SERVICES INC

1905 AMERICAN WAY

KINGSPORT,TN37660
86-1103148 		HEALTHCARE TN 501C3 11A WHS
 
 
No
(5) TAKOMA REGIONAL HOSPITAL INC

401 TAKOMA AVENUE

GREENEVILLE,TN37743
51-0603966 		HEALTHCARE TN 501C3 3 WHS
 
 
No
(6) WELLMONT HAWKINS CTY MEM HOSPITAL

1905 AMERICAN WAY

KINGSPORT,TN37660
62-1816368 		HEALTHCARE TN 501C3 3 WHS
 
 
No
(7) WELLMONT CARDIOLOGY SERVICES

1905 AMERICAN WAY

KINGSPORT,TN37660
26-3557623 		HEALTHCARE TN 501C3 3 WHS
 
 
No
(8) WELLMONT SLEEP SERVICES

1905 AMERICAN WAY

KINGSPORT,TN37660
27-3777167 		HEALTHCARE TN 501C3 3 WHS
 
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) HOLSTON VALLEY IMAGING CENTER

103 WEST STONE DRIVE
KINGSPORT,TN37660
20-2043285 		HEALTHCARE TN N/A
         No     No  
(2) SAPLING GROVE AMBULATORY SURGERY

220 MEDICAL PARK BOULEVARD
BRISTOL,TN37620
20-4450153 		HEALTHCARE TN N/A
         No     No  
(3) HOLSTON VALLEY AMBULATORY SURGERY

103 WEST STONE DRIVE
KINGSPORT,TN37660
62-1816864 		HEALTHCARE TN N/A
         No     No  
(4) HOLSTON VALLEY IMAGING CENTER

103 WEST STONE DRIVE
KINGSPORT,TN37660
20-2043285 		HEALTHCARE TN N/A
         No     No  
(5) SAPLING GROVE AMBULATORY SURGERY

220 MEDICAL PARK BOULEVARD
BRISTOL,TN37620
20-4450153 		HEALTHCARE TN N/A
         No     No  
(6) HOLSTON VALLEY AMBULATORY SURGERY

103 WEST STONE DRIVE
KINGSPORT,TN37660
62-1816864 		HEALTHCARE TN N/A
         No     No  


Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) WELLMONT INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1320035 		PHYS SVCS TN N/A
        
(2) WELLMONT MALL PHARMACY INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1565006 		MED SVCS TN N/A
        
(3) WELLMONT PHYSICIANS SERVICES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1567353 		PHYS SVCS TN N/A
        
(4) WELLMONT HEALTH SERVICES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1254373 		HEALTHCARE TN N/A
        
(5) WPS PROVIDERS INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-5564642 		PHYS SVCS TN N/A
        
(6) MCOT INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1325938 		MED SVCS TN N/A
        
(7) MEDICAL LAUNDRY OF TRI-CITIES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1482226 		MED SVCS TN N/A
        
(8) WELLMONT INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1320035 		PHYS SVCS TN N/A
        
(9) WELLMONT MALL PHARMACY INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1565006 		MED SVCS TN N/A
        
(10) WELLMONT PHYSICIANS SERVICES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1567353 		PHYS SVCS TN N/A
        
(11) WELLMONT HEALTH SERVICES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1254373 		HEALTHCARE TN N/A
        
(12) WPS PROVIDERS INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-5564642 		PHYS SVCS TN N/A
        
(13) MCOT INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1325938 		MED SVCS TN N/A
        
(14) MEDICAL LAUNDRY OF TRI-CITIES INC
1905 AMERICAN WAY
KINGSPORT,TN37660
62-1482226 		MED SVCS TN N/A
        
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) WELLMONT HEALTH SYSTEM

 K 547,832 SERVICE AGREEMENT
(2) WELLMONT HEALTH SYSTEM

 I 45,201 LEASE AGREEMENT
(3) WELLMONT HEALTH SYSTEM

 J 153,077 LEASE AGREEMENT
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


Software ID:  
Software Version: