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
THE CHILDREN'S HOSPITAL OF PHILADELPHIA PRACTICE ASSOCIATION
Employer identification number
23-2311482
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
(A)
THE CHILDREN'S HOSPITAL OF PHILADELPHIA
231352166
03
Yes
Yes
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
0 %
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
THE CHILDREN'S HOSPITAL OF PHILADELPHIA PRACTICE ASSOCIATION
Employer identification number
23-2311482
Return Reference
Explanation
FORM 990, PART IV, LINE 12
AN AUDIT IS PERFORMED ON AN OBLIGATED GROUP WHICH COMPRISES THE CHILDREN'S HOSPITAL OF PHILADELPHIA, THE CHILDREN'S HOSPITAL OF PHILADELPHIA FOUNDATION, AND FIRST MEDICAL INSURANCE COMPANY. An audit is also performed on a consolidated basis which includes the obligated group, PGH Development Corporation, Children's Anesthesiology Associates, Ltd., Children's Anesthesiology Associates of NJ, Inc., Children's Health Care Associates, Inc., Children's Health Care Associates of NJ, Children's Surgical Associates Ltd., Children's Surgical Associates of NJ, Inc., Surgical Research and Education Foundation and Radiology Associates of Children's Hospital, Inc. FORM 990, PART VI, SECTION A, LINE 4 The Bylaws were changed to add the Secretary of the Medical Staff of CHOP as an ex-officio voting member to the CHOPPA board, and adjust the number of voting members to the board. In addition, the Bylaws clarify that subject to the CHOP bylaws, both the physician-in-chief and surgeon-in-chief will be appointed to the CHOP board as voting members. FORM 990, PART VI, LINE 6 The Children's Hospital of Philadelphia is the sole member of CHOPPA. Form 990, Part VI, Line 7a The Children's Hospital of Philadelphia appoints members to the CHOPPA board. All decisions of the board are subject to CHOP's approval. Form 990, Part VI, Line 8b There are no committees with authority to act on behalf of the board. Form 990, Part VI, Section B, Line 11B A copy of this return was reviewed by the executive committee of CHOPPA. Board members who are not members of the executive committee were provided access to the return through a secure website maintained by The Children's Hospital of Philadelphia. FORM 990, PART VI, SECTION B, LINE 12 The organization has adopted the conflicts of interest policy of the Children's Hospital of Philadelphia. The Children's Hospital of Philadelphia maintains a written Conflicts of Interest Policy that applies to, inter alia, all of its Trustees, officers, employees, members of the Medical Staff and researchers of The Children's Hospital of Philadelphia and its affiliates. The Policy requires annual conflicts of interest statements from: Trustees and officers of the Hospital and its affiliates; the President and others in Senior Management; administrative personnel serving at the level of manager and above and certain other categories of employees defined in the conflicts of interest policy (such as persons known to place orders with vendors); Department Chairs, division chiefs and other members of the Medical Staff; members of the Hospital Research Staff; designated employees of practice plans affiliated with the Hospital; and other persons designated by management. The statement tracks the conflicts of interest policy, requiring each person to disclose information for the reporting period regarding the existence and nature of gifts, outside interests, outside activities and other matters constituting a potential, perceived or actual conflict of interest, and to certify that they have read the policy and answered fully, accurately and to the best of their knowledge. After confirmation that all questions have been answered, the statements are reviewed by the relevant Vice President, Department Chair or other executive (or their designee), tracked by the Office of Compliance and Privacy (OC&P), and all statements disclosing potential, perceived or actual conflicts are reviewed initially by the OC&P with further review and follow-up as needed conducted by the Office of General Counsel (OGC). The conflicts statements submitted by Trustees of the Hospital and Foundation, and members of Senior Management, are reviewed by the OGC and OC&P and the disclosures are summarized in memoranda distributed to and reviewed by the members of the Audit and Compliance Committee of the Hospital and Foundation Boards. The remaining conflicts statements containing affirmative disclosures are reviewed by staff in the OGC and OC&P. In reviewing annual statements where an actual, perceived or potential conflict is disclosed, where problems are identified that need to be addressed, the goal is to eliminate or manage the conflict going forward and ensure that, as to employees or others on the Medical or Research Staff, the relevant supervisor is aware of the issue. Summary information about compliance with the policy's requirement to submit annual statements and disclosures contained therein is provided in memoranda to the Audit and Compliance Committee of the Boards. In addition, if any matter involving a potential violation of the conflict of interest policy is brought to the attention of management during the course of the year, a review is conducted by either the relevant department's management, OGC or OC&P, as appropriate. Form 990, Part VI, Section B, Line 15 The compensation of executives and physicians/scientists is reviewed and approved by an independent Compensation Committee of the Board of Trustees. The Committee reviews and approves in advance the compensation to be provided to the CEO, all Vice Presidents (including Executive and Senior VP levels), Clinical Department Chairs, and all faculty physicians and scientists. For each such person, this process was last performed in 2013. In making its determinations, the Committee considers the performance of the organization and that of the covered individuals as well as related business judgment factors. It also considers market comparison reports prepared by an external independent compensation consultant with significant experience in performing executive and physician compensation assessments for not-for-profit healthcare organizations. The Committee's process is designed to qualify for the rebuttable presumption of reasonableness for those individuals who are disqualified persons. The peer group for executives generally includes large and complex academic medical centers and health systems. For physicians and scientists, the peer group generally includes academic medical centers. Information from other organizations may also be considered where appropriate for the position. Form 990, Part VI, Line 19 Form 990 and financial statements are made available upon request. The conflicts of interest policy is available on The Children's Hospital of Philadelphia's website. Form 990, Part XI, Line 9 CHOP Subsidy $5,275,761
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.