Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Olathe Medical Services Inc
Employer identification number
48-1088982
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
0
150
0
0
0
150
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......
51,256,321
50,771,296
52,873,808
54,307,358
54,999,458
264,208,241
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
0
0
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
0
0
0
6
Total. Add lines 1 through 5.
51,256,321
50,771,446
52,873,808
54,307,358
54,999,458
264,208,391
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
0
0
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.
0
0
0
0
0
0
c
Add lines 7a and 7b..
0
0
0
0
0
0
8
Public support (Subtract line 7c from line 6.)
264,208,391
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
51,256,321
50,771,446
52,873,808
54,307,358
54,999,458
264,208,391
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
23,978
36,260
7,948
4,005
2,303
74,494
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
23,978
36,260
7,948
4,005
2,303
74,494
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
0
0
0
0
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
74,908
214,272
177,338
281,030
922,318
1,669,866
13
Total support. (Add lines 9, 10c, 11, and 12.)..
51,355,207
51,021,978
53,059,094
54,592,393
55,924,079
265,952,751
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
99.344 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.634 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.028 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.037 %
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Olathe Medical Services Inc
Employer identification number
48-1088982
Return Reference
Explanation
FORM 990, PART III, LINE 4A
OLATHE MEDICAL SERVICES, INC. (OMSI) CARRIES OUT THEIR MISSION BY PROVIDING PHYSICIAN AND ANCILLARY SERVICES TO THE GENERAL PUBLIC IN THEIR SERVICE AREA REGARDLESS OF RACE, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. OMSI NOT ONLY PROVIDES PHYSICIAN AND ANCILLARY SERVICES IN THE OLATHE, KANSAS AREA BUT ALSO IN RURAL AND/OR MEDICALLY UNDERSERVED AREAS IN THE SURROUNDING COUNTIES. IN 2013, OMSI PROVIDED PHYSICIAN AND ANCILLARY SERVICES AS FOLLOWS: PROGRAM NAME NUMBER OF VISITS PRIMARY CARE PHYSICIAN SERVICES 294,197 SPECIALISTS PHYSICIAN SERVICES 103,523 OMSI'S CONTRIBUTIONS TO THE HEALTH OF THE COMMUNITIES INCLUDES: CHARITY AND UNCOMPENSATED CARE OLATHE MEDICAL SERVICE'S MISSION IS TO PROVIDE QUALITY AND COMPASSIONATE HEALTH CARE SERVICES TO INDIVIDUALS IN THE COMMUNITIES IT SERVES. OLATHE MEDICAL SERVICES PROVIDES HEALTH CARE TO INDIVIDUALS WHO HAVE INADEQUATE RESOURCES TO AFFORD THE SERVICES AND ARE UNINSURED OR UNDERINSURED OR PARTICIPATE IN GOVERNMENTAL HEALTH PROGRAMS FOR THE POOR, ELDERLY OR DISABLED. UNCOMPENSATED CARE TO THE POOR INCLUDES THE COST OF PROVIDING CARE TO PATIENTS WHO MEET THE GUIDELINES OF THE OLATHE MEDICAL SERVICES' CHARITY CARE PROGRAM AND THE COST OF PROVIDING CARE IN EXCESS OF REIMBURSEMENT TO PARTICIPANTS IN THE MEDICAID PROGRAM AND OTHER INDIGENT PUBLIC PROGRAMS SUCH AS FREE CLINICS. CHARITY CARE PROVIDED AT COST $621,000 MEDICAID COST IN EXCESS OF PAYMENTS $2,064,000 PROVISION OF CARE IN RURAL HEALTH CLINICS Olathe Medical Services, Inc. has 5 rural health clinics operating in areas designated as medically underserved. These clinics help meet the needs of their respective communities by providing primary care physicians and mid-level providers, lab services and x-ray services. RURAL HEALTH CARE CLINICS COST IN EXCESS OF PAYMENTS $1,150,000 EDUCATIONAL SUPPORT IN ADDITION TO PROVIDING UNCOMPENSATED CARE FOR PATIENTS IN NEED, OLATHE MEDICAL SERVICES PROVIDES OTHER HEALTH CARE RELATED BENEFITS TO THE COMMUNITIES IT SERVES BY PROVIDING EDUCATION FOR A VARIETY OF MEDICAL PROFESSIONALS, INCLUDING MEDICAL STUDENTS' HEALTH CARE SCREENINGS, NURSING STUDENTS, MID-LEVEL PROVIDERS, AND PHYSICIANS. THE COST OF THIS SUPPORT IS $410,000.
FORM 990, PART VI, SECTION A, LINE 2
FRANK H DEVOCELLE AND TIERNEY L GRASSER HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER. THEY SERVE AS OFFICERS FOR OLATHE HEALTH DEVELOPMENT CORPORATION AND OLATHE MEDICAL CENTER DOCTOR'S BUILDING CONDOMINIUM OWNERS ASSOCIATION, INC., WHICH ARE RELATED FOR PROFIT COMPANIES. DAVID R GABOURY, JAMES R HUBBARD, KENNETH A STELZER, ELAINE TATHAM, CHIP WOOD, FRANK H DEVOXELLE, TIERNEY L GRASSER, AND CHERYL L ROSS HAVE A BUSINESS RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 6
OLATHE MEDICAL CENTER, INC., A NOT-FOR-PROFIT, 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF OLATHE MEDICAL SERVICES, INC.
FORM 990, PART VI, SECTION A, LINE 7A
OLATHE MEDICAL CENTER, INC. IS THE SOLE MEMBER OF OLATHE MEDICAL SERVICES, INC. AND HAS THE RIGHT TO ELECT OR APPOINT ALL THE BOARD OF TRUSTEES.
FORM 990, PART VI, SECTION A, LINE 7B
OLATHE MEDICAL CENTER, INC. IS THE SOLE MEMBER, AND HAS THE RIGHT TO APPROVE OLATHE MEDICAL SERVICES, INC.'S BYLAWS AND ARTICLES OF INCORPORATION AND ALSO APPROVE OLATHE MEDICAL SERVICES' BOARD MEMBERS AND CERTAIN CAPITAL EXPENDITURES OVER $500,000.
FORM 990, PART VI, SECTION B, LINE 11B
The tax return form 990 is reviewed by the Audit and compliance Committee of the Olathe Medical Center, Inc. (Olathe Medical Services, Inc.'s sole member) board on behalf of all of its affiliates prior to filing the return with the Internal Revenue Service. The Audit & Compliance Committee is comprised of independent Board members of Olathe Medical Center, Inc. The final form 990 with all required schedules is then provided to all board members for review prior to filing the form 990.
FORM 990, PART VI, SECTION B, LINE 12C
The purpose of the Organization's Conflict of Interest Policy is to protect the organization's interest when it is contemplating a decision or entering into a transaction or arrangement that might benefit the private interest of any person in a position of authority over the organization, or might result in a possible excess benefit transaction. Corporate officers and members of the Board of Trustees review the Conflict of Interest Policy and complete a Disclosure of Information Form annually. A summary of the annual disclosures of information is provided to the full Board for review at least one time per year. The conflict of interest policy calls for any interested person to disclose the existence of a financial relationship or competitive interest in connection with any pending transaction or arrangement. The individual is given the opportunity to disclose all material facts to the Trustees considering the proposed transaction or arrangement that gave rise to the disclosure. When a transaction involves an interested party, the following procedures are followed: 1. The interested party leaves the meeting after providing any material facts or discussion regarding the matter that gives rise to the interest unless requested to stay by the remaining board or committee members. 2. If appropriate, the Board may appoint a non-interested person or committee to investigate alternatives to the proposed transaction. 3. The interested trustee may not vote in the matter that gives rise to the interest. 4. In order to approve the transaction, the Board must first find, by a majority vote of the trustees then in office, without counting the vote of the interested trustee, a. That the proposed transaction is in the Organization's best interests and for its own benefit, and b. That, after reasonable investigation, the Board has determined that the Organization cannot obtain a more advantageous transaction with reasonable efforts under the circumstances.
FORM 990, PART VI, SECTION B, LINES 15A & B
THE COMPENSATION COMMITTEE OF THE OLATHE MEDICAL CENTER, INC. (OLATHE MEDICAL SERVICES, INC.'S SOLE MEMBER) IS COMPRISED OF INDEPENDENT MEMBERS OF THE BOARD OF OLATHE MEDICAL CENTER, INC. THE COMPENSATION COMMITTEE REVIEWS AND APPROVES THE CEO AND OTHER OFFICERS OF THE COPRORATION'S COMPENSATION IN ACCORDANCE WITH THEIR COMPENSATION POLICY. THE COMPENSATION COMMITTEE REVIEWS THIRD PARTY SALARY SURVEYS, USES INDEPENDENT CONSULTANTS AND ALSO UTILIZES WRITTEN CONTRACTS FOR THE CEO AND THE VP/PHYSICIAN SERVICES TO DETERMINE THE FAIR MARKET VALUE OF THE CURRENT COMPENSATION, SALARY RANGES AND BENEFITS.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC.
FORM 990, PART XI, LINE 5
TRANSFER FROM AFFILIATE $22,193,453
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.