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
SOUTH NASSAU COMMUNITIES HOSPITAL
Employer identification number
27-2843521
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)
No
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
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
(A)
SOUTH NASSAU COMMUNITIES HOSPITAL
111352310
HOSPITAL
Yes
0
Total
0
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
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
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
SOUTH NASSAU COMMUNITIES HOSPITAL
Employer identification number
27-2843521
Return Reference
Explanation
PART I, LINE 1
THE MISSION OF SNCH'S AFFILIATES IS TO PROVIDE HIGH QUALITY, COMPREHENSIVE AND EASILY ACCESSIBLE HEALTH CARE TO ALL RESIDENTS OF THE SOUTH SHORE COMMUNITIES IN SUPPORT OF THE HOSPITAL.
PART III, LINE 1
THE MISSION OF SOUTH NASSAU COMMUNITIES HOSPITAL'S AFFILIATES ("THE AFFILIATES") IS TO PROVIDE HIGH QUALITY, COMPREHENSIVE AND EASILY ACCESSIBLE HEALTH CARE TO ALL RESIDENTS OF THE SOUTH SHORE COMMUNITIES IN A MANNER WHICH REFLECTS A CULTURE OF EXCELLENCE, PERSONALIZED, CULTURALLY COMPETENT CARE AND INNOVATION IN SUPPORT OF THE HOSPITAL'S MISSION.
PART III, LINE 4A
SOUTH NASSAU MEDICAL GROUP P.C., PROVIDE PRIMARY MEDICAL AND CARDIOVASCULAR CARE SERVICES AND EXPERIENCED 34,296 VISITS IN 2013. THE PC IS CONTROLLED AND OPERATED BY SOUTH NASSAU COMMUNITIES HOSPITAL.
PART III, LINE 4B
SOUTH NASSAU PHYSICIAN PRACTICE PROVIDES PHYSICIAN SERVICES TO PATIENTS. THE PC IS CONTROLLED AND OPERATED BY SOUTH NASSAU COMMUNITIES HOSPITAL.
PART III, LINE 4C
SOUTH NASSAU ONCOLOGY PC PROVIDES MEDICAL CARE AND RELATED SERVICES TO CANCER PATIENTS, RENDERED IN THE GREATER NASSAU COUNTY COMMUNITIES. THE PC IS CONTROLLED AND OPERATED BY SOUTH NASSAU COMMUNITIES HOSPITAL.
FORM 990, PART VI, SECTION A, LINE 6
SOUTH NASSAU COMMUNITIES HOSPITAL IS THE SOLE MEMBER OF 14 ENTITIES: SOUTH NASSAU PRIMARY MEDICAL CARE, P.C., SOUTH NASSAU FAMILY MEDICINE, P.C., OCEANSIDE COUNSELING CENTER INC., S.N. SERVICES CORP, SOUTH NASSAU NEONATAL SERVICES, P.C., SOUTH NASSAU PHYSICIAN PRACTICE, P.C., SOUTH NASSAU ONCOLOGY, P.C., SOUTH NASSAU CARDIOVASCULAR PRACTICE, P.C., 203 MERRICK ROAD, SN RADIOLOGICAL PRACTICE, P.C., SOUTH NASSAU MEDICAL GROUP, P.C., SOUTH NASSAU OBSTETRICS AND GYNECOLOGY, P.C., SOUTH NASSAU ONCOLOGY PRACTICE, P.C., AND RADIOLOGICAL ASSOCIATES OF LONG ISLAND, P.C. THE SYSTEM IS ORGANIZED AS A NOT FOR PROFIT CORPORATION UNDER FEDERAL AND NEW YORK STATE LAWS.
FORM 990, PART VI, SECTION A, LINE 7A
SOUTH NASSAU COMMUNITIES HOSPITAL HAS THE AUTHORITY TO ELECT THE OFFICERS OF THE ORGANIZATIONS COVERED IN THIS RETURN. SOUTH NASSAU ALSO HAS THE AUTHORITY TO MAKE ANY MANAGING DECISIONS FOR THE ORGANIZATIONS COVERED IN THIS RETURN.
FORM 990, PART VI, SECTION A, LINE 7B
THE BOARD HAS THE AUTHORITY (I) ELECT AND REMOVE MEMBERS OF THE TAXPAYER'S GOVERNING BOARD, (II) APPROVE AMENDMENTS TO THE TAXPAYER'S CERTIFICATE OF INCORPORATION AND BYLAWS, AND (III) APPROVE SIGNIFICANT CORPORATE TRANSACTIONS SUCH AS MERGERS, OTHER AUTHORITY INCLUDES: (A) APPROVAL OF THE TAXPAYER'S MISSION AND PHILOSOPHY; (B) ESTABLISHING THE SIZE OF THE TAXPAYER'S GOVERNING BOARD; (C) SELECTION AND REMOVAL OF THE CHAIRPERSON OF THE TAXPAYER'S GOVERNING BOARD; (D) ESTABLISHING CRITERIA FOR EVALUATING PERFORMANCE OF THE TAXPAYER'S CHIEF EXECUTIVE OFFICER; (E) APPROVAL OF THE TAXPAYER'S OPERATING AND CAPITAL BUDGETS AND BUSINESS PLAN; (F) APPROVAL OF THE ESTABLISHMENT OF ANY MATERIAL NEW LINES OF BUSINESS BY THE TAXPAYER THAT IS NOT OTHERWISE CONTEMPLATED WITHIN A PREVIOUSLY APPROVED BUSINESS PLAN OF THE TAXPAYER; (G) INITIATION BY THE TAXPAYER OF A BANKRUPTCY OR INSOLVENCY ACTION; (H) APPROVAL OF THE ISSUANCE OF LONG-TERM DEBT (I) APPROVAL OF LITIGATION SETTLEMENTS INVOLVING THE TAXPAYER THAT EXCEED APPLICABLE COMMERCIAL OR SELF-INSURANCE COVERAGE; (J) APPROVAL OF THE SUBMISSION OF ANY CERTIFICATE OF NEED APPLICATIONS BY OR ON BEHALF OF THE TAXPAYER WITH ANY REGULATORY AUTHORITY; (K) APPROVAL OF THE INITIATION BY THE TAXPAYER OF A NEW CLINICAL SERVICE OR THE DISCONTINUANCE OR SUBSTANTIAL CHANGE IN AN EXISTING CLINICAL SERVICE.
FORM 990, PART VI, SECTION B, LINE 11
THE AFFILIATES OF SOUTH NASSAU COMMUNITIES HOSPITAL REVIEW AND APPROVE THE IRS FORM 990 ACCORDING TO THE POLICY OF THE PARENT ORGANIZATION, SOUTH NASSAU COMMUNITIES HOSPITAL. AS SUCH, SOUTH NASSAU COMMUNITIES HOSPITAL'S PROCESS IS OUTLINED BELOW: THE AUDIT COMMITTEE, A SUB-COMMITTEE OF THE BOARD OF DIRECTORS, IS ASSIGNED TO REVIEW THE IRS FORM 990 THAT IS FILED ON BEHALF OF THE ORGANIZATION BEFORE IT IS FILED WITH THE IRS. THE AUDIT COMMITTEE WILL NOTIFY THE BOARD OF DIRECTORS WHEN THE IRS FORM 990 IS APPROVED BY THE AUDIT COMMITTEE. ONCE THE 990 IS APPROVED, THE BOARD OF DIRECTORS OF SOUTH NASSAU COMMUNITIES HOSPITAL WILL RECEIVE A COPY (ELECTRONICALLY OR HARDCOPY) BEFORE IT IS ULTIMATELY FILED WITH THE INTERNAL REVENUE SERVICE.
FORM 990, PART VI, SECTION B, LINE 12C
ENFORCEMENT OF CONFLICTS POLICY THE AFFILIATES OF SOUTH NASSAU COMMUNITIES HOSPITAL'S OFFICERS, DIRECTORS, AND KEY EMPLOYEES OPERATE UNDER THE CONFLICT OF INTEREST POLICY OF ITS PARENT ORGANIZATION, SOUTH NASSAU COMMUNITIES HOSPITAL. THE HOSPITAL ANNUALLY MONITORS COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY BY PROVIDING ANNUAL QUESTIONNAIRES THAT REQUIRE THE OFFICER, DIRECTOR AND/OR KEY EMPLOYEE TO DISCLOSE POTENTIAL CONFLICTS. FOR FURTHER INFORMATION, PLEASE REFER TO THE SOUTH NASSAU COMMUNITIES HOSPITAL FORM 990 FOR THE YEAR ENDING DECEMBER 31, 2013.
FORM 990, PART VI, SECTION B, LINE 15
COMPENSATION PROCESS FOR TOP OFFICIAL COMPENSATION FOR THE OFFICERS AND OTHER EMPLOYEES IS DETERMINED BY SOUTH NASSAU COMMUNITIES HOSPITAL.
FORM 990, PART VI, SECTION C, LINE 19
THE PUBLIC CAN OBTAIN A COPY OF THE 990 OR THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS VIA A WRITTEN OR VERBAL REQUEST THROUGH THE HOSPITAL'S OFFICE OF EXTERNAL AFFAIRS, 2277 GRAND AVE., BALDWIN, NY 11510. THE BYLAWS, ARTICLES OF INCORPORATION AND THE CONFLICT OF INTEREST POLICY OF THE SOUTH NASSAU COMMUNITIES HOSPITAL AFFILIATES CAN BE OBTAINED AT MANAGEMENT'S DISCRETION VIA A WRITTEN REQUEST THROUGH THE HOSPITAL'S OFFICE OF EXTERNAL AFFAIRS, 2277 GRAND AVE., BALDWIN, NY 11510. PHONE NUMBER: (516) 377-5370.
FORM 990, PART XI, LINE 9:
TRANSFER FROM AFFILIATES 7,136,193.
FORM 990, PART XII, LINE 2C:
SOUTH NASSAU COMMUNITIES HOSPITAL, THE PARENT OF THESE ORGANIZATIONS, RECEIVED A COMBINED AUDITED FINANCIAL STATEMENT FOR THE YEAR ENDING DECEMBER 31, 2013. THE COMBINED FINANCIAL STATEMENTS ARE PREPARED IN ACCORDANCE WITH ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA ("GAAP"). THE COMBINED FINANCIAL STATEMENTS INCLUDE THE ACCOUNTS OF SOUTH NASSAU COMMUNITIES HOSPITAL AND ALL OF ITS AFFILIATED ORGANIZATIONS WHICH IN SOME CASES FILE SEPARATE RETURNS WITH THE IRS.
FORM 990, PAGE 1, BOX H
AFFILIATES INCLUDED IN GROUP RETURN SUBORDINATE ORGANIZATIONS OF SOUTH NASSAU COMMUNITIES HOSPITAL (EIN: 27-2843521) GROUP EXEMPTION NUMBER 5611: - SOUTH NASSAU PRIMARY MEDICAL CARE, P.C. EIN: 11-3581988 - SOUTH NASSAU FAMILY MEDICINE, P.C. EIN: 11-3565450 - OCEANSIDE COUNSELING CENTER INC. EIN: 23-7062966 - S.N. SERVICES CORP EIN: 11-2727976 - SOUTH NASSAU NEONATAL SERVICES, P.C. EIN: 11-3319620 - SOUTH NASSAU PHYSICIAN PRACTICE, P.C. EIN: 26-2692377 - SOUTH NASSAU ONCOLOGY, P.C. EIN: 27-3857309 - SOUTH NASSAU CARDIOVASCULAR PRACTICE, P.C. EIN: 38-3843950 - 203 MERRICK ROAD EIN: 27-5368294 - SN RADIOLOGICAL PRACTICE, P.C. EIN: 27-4344388 - SOUTH NASSAU MEDICAL GROUP, P.C. EIN: 45-4799159 - SOUTH NASSAU OBSTETRICS AND GYNECOLOGY, P.C. EIN: 45-5272144 - RADIOLOGICAL ASSOCIATES OF LONG ISLAND, P.C. EIN: 11-2462030
PART VI, LINE 13
THE AFFILIATES OF SOUTH NASSAU COMMUNITIES HOSPITAL OPERATE UNDER THE WRITTEN WHISTLE BLOWER AND DOCUMENT RETENTION POLICIES OF ITS PARENT ORGANIZATION, SOUTH NASSAU COMMUNITIES HOSPITAL.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.