Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
GWINNETT MEDICAL GROUP INC
Employer identification number
58-2143107
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here........................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2011.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2012.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2011.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
GWINNETT MEDICAL GROUP INC
Employer identification number
58-2143107
Identifier
Return Reference
Explanation
ORGANIZATION'S MISSION
FORM 990 - ORGANIZATION'S MISSION
GWINNETT MEDICAL GROUP, INC. (GMGI), FORMERLY GWINNETT MEDICAL SERVICES, INC., WAS FORMED FOR THE PURPOSE OF ESTABLISHING AND OPERATING CERTAIN HOSPITAL BASED AND CLINICAL OUTREACH PHYSICIAN SERVICES WITHIN OUR SERVICE COMMUNITY. GMGI EMPLOYS SPECIALTY PHYSICIANS THAT SERVE PATIENTS WITHIN GWINNETT HOSPITAL SYSTEM, INC. AND PRIMARY CARE AND OTHER PHYSICIANS THAT SERVE PATIENTS IN CLINICAL SETTINGS WITHIN THE COMMUNITY. THESE PHYSICIAN SERVICES ARE AN INTEGRAL PART OF THE HEALTHCARE MISSION OF GWINNETT HOSPITAL SYSTEM, INC. AND GWINNETT HEALTH SYSTEM, INC.
ANY SIGNIFICANT NEW PROGRAM SERVICES NOT LISTED ON A PRIOR RETURN
FORM 990, PAGE 2, PART III, LINE 2
DURING THE FISCAL YEAR, GWINNETT MEDICAL GROUP ACQUIRED A CARDIOLOGY PRACTICE. AT YEAR END, THE PRACTICE HAD ELEVEN (11) FULL TIME BOARD CERTIFIED CARDIOLOGISTS AND NINE (9) MID-LEVEL PROVIDERS.
FIRST ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4A
PHYSICIANS WHOSE PATIENTS MAY HAVE COMPLICATIONS OR COMORBIDITIES THAT REQUIRE FURTHER MEDICAL MANAGEMENT. DURING NORMAL CENSUS, THERE ARE NINE PHYSICIANS ON DUTY AT GMC AND THREE AT GMCD. THE ESTIMATED AVERAGE DAILY CENSUS FOR GMC IS 130 PATIENTS AND FOR GMCD, 35 PATIENTS.
SECOND ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4B
ENCOUNTERS. CVG OFFERS A FULL RANGE OF CARDIOVASCULAR SERVICES AND STRUCTURAL HEART SERVICES. CVG IS A HIGHLY INTEGRATED, MULTIDISCIPLINARY HEALTH CARE TEAM. CVG STRIVES TO SATISFY THEIR PATIENTS' NEEDS BY COMPASSIONATELY APPLYING THE HIGHEST LEVEL OF PREVENTIVE, DIAGNOSTIC AND THERAPEUTIC TREATMENT SERVICES FOR CARDIOVASCULAR RELATED CONDITIONS.
THIRD ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4C
PLUS 954 DELIVERIES, FOR A COMBINED TOTAL OF 4,031 INPATIENT VISITS IN FISCAL YEAR 2013. THE OB/GYN PRACTICE SERVES THE UNINSURED AND UNDER- INSURED POPULATION OF GWINNETT COUNTY.
ALL OTHER ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4D
OTHER PATIENT CARE PROGRAMS - PROGRAM SERVICE EXPENSES 14,977,378; PROGRAM SERVICE REVENUES 7,903,158
SIGNIFICANT CHANGES TO ORGANIZATIONAL DOCUMENTS
FORM 990, PAGE 6, PART VI, LINE 4
THE ORGANIZATION'S BYLAWS WERE AMENDED TO REQUIRE A MAJORITY OF THE BOARD OF DIRECTORS BE COMPRISED OF INDEPENDENT DIRECTORS, AS DEFINED IN THE INSTRUCTIONS TO FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX.
CLASSES OF MEMBERS OR STOCKHOLDERS
FORM 990, PAGE 6, PART VI, LINE 6
THE SOLE MEMBER OF GWINNETT MEDICAL GROUP, INC. IS THE GWINNETT HEALTH SYSTEM INC. A RELATED 501(C)(3) ORGANIZATION.
ELECTION OF MEMBERS AND THEIR RIGHTS
FORM 990, PAGE 6, PART VI, LINE 7A
GWINNETT MEDICAL GROUP, INC. IS CONTROLLED BY GWINNETT HEALTH SYSTEM, INC. WHICH HAS FINAL AUTHORITY OVER THE ELECTION OF THE GOVERNING BODY OF THE ORGANIZATION.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS
FORM 990, PAGE 6, PART VI, LINE 7B
UNDER THE ORGANIZATION'S GOVERNING DOCUMENTS, CERTAIN DECISIONS MADE BY THE GOVERNING BODY MUST BE APPROVED BY THE GWINNETT HEALTH SYSTEM, INC. (A RELATED SECTION 501(C)(3) PARENT ORGANIZATION), THE SOLE MEMBER OF GWINNETT MEDICAL GROUP INC.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990
FORM 990, PAGE 6, PART VI, LINE 11B
INFORMATION FOR THE PREPARATION OF THIS RETURN WAS PROVIDED TO AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT. AFTER THE RETURN WAS PREPARED AND PRIOR TO FILING, IT WAS REVIEWED IN DETAIL BY SENIOR FINANCIAL MANAGEMENT. GWINNETT MEDICAL GROUP, INC. THEN MADE A COPY OF FORM 990 AVAILABLE FOR REVIEW TO ALL BOARD MEMBERS THROUGH A SECURE WEBSITE PRIOR TO FILING.
ENFORCEMENT OF CONFLICTS POLICY
FORM 990, PAGE 6, PART VI, LINE 12C
A CONFLICTS OF INTEREST QUESTIONNAIRE IS DISCUSSED WITH AND DISTRIBUTED TO EACH BOARD MEMBER ANNUALLY. THE LEGAL DEPARTMENT IS RESPONSIBLE FOR ENSURING THESE QUESTIONNAIRES ARE SIGNED AND RETURNED. LEGAL MONITORS ALL TRANSACTIONS INVOLVING CONFLICTS OF INTEREST WITH BOARD MEMBERS. BOARD MEMBERS MUST DISCLOSE POTENTIAL CONFLICTS OF INTEREST USING A REASONABLE BELIEF STANDARD; PLAY NO DIRECT OR INDIRECT PART IN DELIBERATION; AND RECUSE THEMSELVES FROM ANY MEETING AT WHICH A POTENTIAL CONFLICT IS DISCUSSED. ONLY NONCONFLICTED MEMBERS MAY DECIDE TO PURSUE A TRANSACTION OR ARRANGEMENT INVOLVING A CONFLICT IF A MAJORITY DETERMINES THE TRANSACTION OR ARRANGEMENT IS IN THE ORGANIZATION'S BEST INTEREST. VIOLATION OF THE COI POLICY IS SUBJECT TO CORRECTIVE ACTION, INCLUDING EXONERATION, CENSURE AND REQUESTING RESIGNATION OF THE MEMBER. APPROVAL FOR ANY LOANS, PAYMENTS, HONORARIUMS, TRIP OR TRAVEL REIMBURSEMENTS, SERVICES, PRODUCTS, ENTERTAINMENT, PRIZES OR AWARDS PROVIDED TO ANY BOARD MEMBER MUST BE APPROVED BY AN ADMINISTRATIVE OFFICER OR HIS/HER DESIGNEE. THE CEO MUST OBTAIN THE APPROVAL OF THE CHAIRMAN OF THE BOARD OR ANOTHER EXECUTIVE OFFICER. IN ADDITION , HUMAN RESOURCES SENDS OUT A CONFLICT OF INTEREST POLICY AND DISCLOSURE FORM TO OFFICERS AND KEY EMPLOYEES EVERY 3-5 YEARS. THESE OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS THAT ARISE DURING THE FISCAL YEAR.
COMPENSATION PROCESS FOR OFFICERS
FORM 990, PAGE 6, PART VI, LINE 15B
GWINNETT HEALTH SYSTEM, INC. (HEALTH SYSTEM) BOARD OF DIRECTORS HAS ESTABLISHED A COMPENSATION COMMITTEE MADE UP OF VARIOUS BOARD MEMBERS WHO REVIEW COMPENSATION OF THE CEO, TOP MANAGEMENT, AND OTHER KEY EMPLOYEES THROUGHOUT THE MULTI ENTITY HEALTHCARE SYSTEM. THIS COMPENSATION COMMITTEE IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF THE SALARY OF THE CEO. THE CEO IS REPONSIBLE FOR DETERMINING THE SALARIES OF TOP MANAGEMENT WITH OVERSIGHT BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. AN INDEPENDENT PROFESSIONAL EXECUTIVE COMPENSATION CONSULTING COMPANY HIRED BY THE BOARD PROVIDES SALARY AND BENEFIT SURVEY INFORMATION AND MAKES RECOMMENDATIONS TO THE COMPENSATION COMMITTEE REGARDING COMPENSATION OF THE CEO, TOP MANAGEMENT, AND KEY EMPLOYEES. THESE PERIODIC SURVEYS ARE CONDUCTED TO ENSURE THE SALARIES AND BENEFITS FOR HEALTH SYSTEM AND GMGI EXECUTIVES AND OTHER DISQUALIFIED PARTIES ARE COMPENSATED APPROPRIATELY AT FAIR MARKET VALUE.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION
FORM 990, PAGE 6, PART VI, LINE 19
GOVERNING DOCUMENTS ARE FILED AND AVAILABLE ON THE GEORGIA SECRETARY OF STATE WEBSITE OR THROUGH THAT OFFICE. THESE DOCUMENTS CAN ALSO BE OBTAINED BY CONTACTING GWINNETT HOSPITAL SYSTEM, INC. LIMITED FINANCIAL INFORMATION IS AVAILABLE ONLINE THROUGH THE COMMUNITY BENEFIT REPORT AS WELL AS THE ANNUAL REPORT FOR GHSI, BOTH OF WHICH ARE AVAILABLE ONLINE AT WWW.GWINNETTMEDICALCENTER.ORG. GWINNETT HOSPITAL'S CONFLICT OF INTEREST POLICY CAN BE OBTAINED BY CONTACTING GWINNETT HOSPITAL SYSTEM INC. GWINNETT HOSPITAL SYSTEM, INC IS UNDER OBLIGATION TO DISCLOSE TO BOND HOLDERS PERTINENT FINANCIAL INFORMATION IN THE ANNUAL DISCLOSURE DOCUMENTS. CONTACT INFORMATION FOR GHSI AND GMGI CAN BE OBTAINED AT WWW.GWINNETTMEDICALCENTER.ORG.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.