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
PHYSICIANS CLINIC INC
Employer identification number
47-0687317
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.") .
2,855
671
3,526
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......
100,260,130
108,383,451
119,523,130
127,482,478
134,848,401
590,497,590
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.
100,260,130
108,383,451
119,525,985
127,483,149
134,848,401
590,501,116
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
590,501,116
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...
100,260,130
108,383,451
119,525,985
127,483,149
134,848,401
590,501,116
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
262,367
558,118
975,090
920,299
877,227
3,593,101
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
262,367
558,118
975,090
920,299
877,227
3,593,101
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
3,796
70,394
85,928
77,532
72,658
310,308
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.)..
100,526,293
109,011,963
120,587,003
128,480,980
135,798,286
594,404,525
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
99.340 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.410 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.600 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.550 %
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
PHYSICIANS CLINIC INC
Employer identification number
47-0687317
Return Reference
Explanation
FORM 990, PART V, LINE 2B
THE PAYROLL SYSTEM FOR PHYSICIANS CLINIC IS BEING HANDLED BY A COMMON PAYMASTER, NEBRASKA METHODIST HEALTH SYSTEM INC. ALL W-2 FORMS ARE ISSUED UNDER THE TAX IDENTIFICATION NUMBER OF NEBRASKA METHODIST HEALTH SYSTEM. ALL REQUIRED FEDERAL EMPLOYMENT TAX RETURNS WERE FILED BY NEBRASKA METHODIST HEALTH SYSTEM. WAGES AND BENEFITS SHOWN IN THE FORM 990 ARE ACTUAL WAGES ASSOCIATED WITH PHYSICIANS CLINIC PERSONNEL.
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF PHYSICIANS CLINIC INC. IS NEBRASKA METHODIST HEALTH SYSTEM, INC., A NEBRASKA NOT-FOR-PROFIT CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7A
NEBRASKA METHODIST HEALTH SYSTEM, INC., THE MEMBER, HAS THE POWER TO ELECT AND REMOVE THE DIRECTORS OF THE CORPORATION. THE NEBRASKA METHODIST HEALTH SYSTEM ALSO HAS THE POWER TO APPOINT AND REMOVE THE PERSON DESIGNATED AS THE CORPORATION'S PRESIDENT BY THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B
NEBRASKA METHODIST HEALTH SYSTEM, INC., THE MEMBER, HAS THE POWER TO APPROVE OR REFUSE TO APPROVE ANY AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR THE BYLAWS OR ANY ACTION REQUIRED TO BE SUBMITTED TO AND APPROVED BY THE VOTING MEMBERS OF A NONPROFIT CORPORATION UNDER THE NEBRASKA NONPROFIT CORPORATION ACT. METHODIST HEALTH SYSTEM ALSO HAS APPROVAL AUTHORITY WITH REGARD TO THE ANNUAL BUDGET, CAPITAL EXPENDITURES IN EXCESS OF ESTABLISHED THRESHOLDS, THE MISSION STATEMENT, LONG-RANGE PLAN, INCURRENCE OF DEBT AND ESTABLISHMENT OF A SUBSIDIARY OR PARTICIPATION AS A SHAREHOLDER, PARTNER OR EQUITY MEMBER OF ANY OTHER ENTITY.
FORM 990, PART VI, SECTION B, LINE 11
PHYSICIANS CLINIC INC. IS AN AFFILIATE ORGANIZATION OF NEBRASKA METHODIST HEALTH SYSTEM, INC. POLICIES ARE CENTRALIZED AT NEBRASKA METHODIST HEALTH SYSTEM INC. PRIOR TO FILING THE FORM 990, A COPY IS PROVIDED TO THE AUDIT COMMITTEE OF NEBRASKA METHODIST HEALTH SYSTEM. THE COMMITTEE IS GIVEN AN OPPORTUNITY TO ASK QUESTIONS OR REQUEST MORE INFORMATION AT A SUBSEQUENT MEETING. INFORMATION FOR THE FORM 990 IS GATHERED FROM APPROPRIATE RESPONSIBLE PARTIES THROUGHOUT THE ORGANIZATION, INCLUDING THE ORGANIZATION'S HUMAN RESOURCES, FINANCE AND COMPLIANCE DEPARTMENTS. THE RETURN GETS A DETAIL TIE-OUT AND DIRECTOR OF ACCOUNTING REVIEW. IT IS REVIEWED BY EXTERNAL TAX ADVISORS AND HAS A FINAL REVIEW BY THE CHIEF FINANCIAL OFFICER FOR NEBRASKA METHODIST HEALTH SYSTEM AND THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER.
FORM 990, PART VI, SECTION B, LINE 12C
AN ANNUAL QUESTIONNAIRE IS SENT TO ALL OFFICERS, DIRECTORS AND KEY EMPLOYEES PURSUANT TO THE METHODIST HEALTH SYSTEM CONFLICTS OF INTEREST POLICY WHICH REQUIRES THE DISCLOSURE OF RELATIONSHIPS, NOT JUST FINANCIAL, THAT COULD GIVE RISE TO CONFLICTS WITH THE ORGANIZATION. A BOARD COMMITTEE MEETS ANNUALLY TO REVIEW ALL POTENTIAL CONFLICTS IDENTIFIED THROUGH THE SURVEYS. SHOULD A DECISION COME TO THE BOARD WITH AN IDENTIFIED CONFLICT, THE OFFICER, DIRECTOR OR KEY EMPLOYEE IS NOT PERMITTED TO VOTE OR USE PERSONAL INFLUENCE ON THE MATTER AND IS NOT COUNTED IN DETERMINING A QUORUM FOR A MEETING AT WHICH THE MATTER IS DISCUSSED. A POTENTIAL CONFLICT OF INTEREST, ONCE IDENTIFIED, MUST BE EVALUATED ON A CASE BY CASE BASIS. IN ORDER TO APPROVE THE TRANSACTION WHICH INVOLVES A DIRECT CONFLICT OF INTEREST, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DIRECTORS FOR WHOM NO CONFLICT EXISTS, AT A MEETING AT WHICH A QUORUM IS PRESENT, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE BEST INTEREST OF PHYSICIANS CLINIC AND/OR METHODIST HEALTH SYSTEM AFFILIATES, IS FAIR AND REASONABLE, AND AFTER INVESTIGATION, THE DIRECTORS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES.
FORM 990, PART VI, SECTION B, LINE 15
PHYSICIANS CLINIC IS AN AFFILIATED MEMBER OF THE NEBRASKA METHODIST HEALTH SYSTEM. METHODIST HEALTH SYSTEM RETAINS AN INDEPENDENT CONSULTANT TO REVIEW ALL OFFICER COMPENSATION FOR EACH AFFILIATE. UNDER THIS PROCESS, MARKET DATA ON COMPENSATION IS GATHERED AND ANALYZED AND COMPENSATION RANGES ARE SET. THIS INFORMATION IS THEN PROVIDED TO THE COMPENSATION COMMITTEE OF THE BOARD OF THE NEBRASKA METHODIST HEALTH SYSTEM INC. ALL OFFICER COMPENSATION IS REVIEWED, EVALUATED AND APPROVED BY THIS COMMITTEE. PHYSICIANS CLINIC(PCI) ADMINISTRATION MAINTAINS A WRITTEN PHYSICIAN COMPENSATION PLAN THAT HAS BEEN REVIEWED BY OUTSIDE COUNSEL AND APPROVED BY PCI ADMINISTRATION AND THE PCI BOARD OF DIRECTORS. THE PLAN DEFINES THE METHODOLOGY FOR DETERMINING PHYSICIAN COMPENSATION AND SITE FINANCIAL ACCOUNTABILITY BONUS. THE PLAN ALSO ADDRESSES THE PAYMENT OF A MONTHLY DRAW TO PHYSICIANS, SALARY GUARANTEES AND TIME-OFF PROVISIONS. INDEPENDENT MARKET REVIEWS AND INTERNAL ANALYSIS OF PHYSICIAN COMPENSATION ARE REGULARLY PERFORMED. EVERY THREE YEARS A FAIR MARKET VALUE ASSESSMENT IS PERFORMED BY AN INDEPENDENT CONSULTANT. THE ANALYSIS IS PERFORMED BY COMPARING INDIVIDUAL PHYSICIAN COMPENSATION FOR EACH AREA OF SPECIALIZATION WITHIN PHYSICIANS CLINIC WITH COMPENSATION AVERAGES THAT HAVE BEEN COMPILED FROM THE AMERICAN MEDICAL GROUP ASSOCIATION (AMGA) AND THE MEDICAL GROUP MANAGEMENT ASSOCIATION (MGMA). THE NEXT INDEPENDENT OPINION WILL BE OBTAINED IN 2015 ON THE 2014 PHYSICIAN COMPENSATION.
FORM 990, PART VI, SECTION C, LINE 18
THE FORM 1023 WAS FILED PRIOR TO 7/15/87 AND NEED NOT BE MADE PUBLICLY AVAILABLE. A COPY OF THE IRS DETERMINATION LETTER WILL BE PROVIDED UPON WRITTEN REQUEST.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS SEPARATELY AVAILABLE TO THE PUBLIC. HOWEVER, THE AMENDED ARTICLES OF INCORPORATION OF THE ORGANIZATION ARE AVAILABLE THROUGH THE NEBRASKA SECRETARY OF STATE'S WEBSITE. THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS AND EMPLOYEES. FINANCIAL INFORMATION IS AVAILABLE TO THE PUBLIC THROUGH THE IRS FORM 990 AND FORM 990-T. THE ORGANIZATION ALSO CONTRIBUTES INFORMATION REGARDING COMMUNITY BENEFITS IT PROVIDES AS PART OF THE METHODIST HEALTH SYSTEM'S ANNUAL COMMUNITY BENEFIT REPORT. THE REPORT IS AVAILABLE TO THE PUBLIC ON THE WEBSITE, WWW.METHODISTCHART.ORG.
FORM 990, PART VII
LINDA BURT, VICE PRESIDENT OF FINANCE AND CFO FOR THE NEBRASKA METHODIST HEALTH SYSTEM, IS A FULLTIME EMPLOYEE OF NEBRASKA METHODIST HEALTH SYSTEM. HER AVERAGE HOURS PER WEEK ARE ALLOCATED AMONG THE ENTITIES THAT COMPRISE THE NEBRASKA METHODIST HEALTH SYSTEM.
FORM 990, PART VII
TODD GRAGES IS A KEY EMPLOYEE OF NEBRASKA METHODIST HEALTH SYSTEM AND IS ASSIGNED FULLTIME DUTIES AS PRESIDENT OF PHYSICIANS CLINIC INC. SALARY AND BENEFITS ARE INCLUDED IN ALLOCATIONS.
FORM 990, PART VII, SECTION A, COLUMN D & E
INDIVIDUALS WHO HAVE COMPENSATION FROM THE ORGANIZATION OR A RELATED ORGANIZATION ARE EMPLOYEES OF THE RESPECTIVE ORGANIZATION. THESE INDIVIDUALS DO NOT RECEIVE COMPENSATION FOR SERVICES ON THE BOARD OF DIRECTORS.
FORM 990, PART XI, LINE 9:
TRANSFERS FROM AFFILIATES 11,531,934.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.