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
St Vincent's Ambulatory Care Inc
Employer identification number
59-2292041
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.") .
402,000
1,544,933
1,161,998
3,108,931
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......
12,111,941
27,939,125
45,373,306
43,739,102
46,281,581
175,445,055
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.
12,111,941
27,939,125
45,775,306
45,284,035
47,443,579
178,553,986
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
402,000
402,000
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..
402,000
402,000
8
Public support (Subtract line 7c from line 6.)
178,151,986
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...
12,111,941
27,939,125
45,775,306
45,284,035
47,443,579
178,553,986
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
468,162
566,300
329,739
336,387
436,579
2,137,167
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
468,162
566,300
329,739
336,387
436,579
2,137,167
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.)
..
176
164,067
51,666
344,622
178,865
739,396
13
Total support. (Add lines 9, 10c, 11, and 12.)..
12,580,279
28,669,492
46,156,711
45,965,044
48,059,023
181,430,549
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
98.190 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
97.830 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.180 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
1.500 %
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
St Vincent's Ambulatory Care Inc
Employer identification number
59-2292041
Return Reference
Explanation
Form 990, Part III:
St. Vincent's Ambulatory Care, Inc. Community benefit report June 30, 2014 This report illustrates the significant degree St. Vincent's Ambulatory Care Inc., ("ACI"), positively contributes to the health status of its' patients and their families in the Northeast Florida and Southeast Georgia communities. ACI is a subsidiary of St. Vincent's HealthCare, a multi entity health care network that provides essential health services to its community. As a member of Ascension Health, the nation's largest not-for-profit Catholic healthcare system, St. Vincent's HealthCare continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. The goal of St. Vincent's HealthCare is to perpetuate the healing mission of the Catholic Church. St. Vincent's HealthCare furthers this goal through delivery of patient services, care to the elderly and indigent, and patient education and health awareness programs for the community. Our concern for all human life and dignity of each person leads the organization to provide medical services to all people in the community without regard to the patient's race, creed, national origin, economic status, or ability to pay. In order to fully portray the breadth of our contribution, ACI's community benefit information is described below: Organizational Commitment to Providing Community Benefit: ACI is comprised of two main branches, the Ambulatory Care Specialty Practices and the Mobile Health Outreach Ministry (MHOM). ACI contains over 61 physicians specializing in Cardiology, Neurosurgery, Neurology, Infectious Disease, Obstetrics & Gynecology, General Surgery, ENT, Pulmonology/Critical Care, Sleep Medicine and Rheumatology. These providers see patients in seventeen different locations, many of them rural markets with limited access to health care. Furthermore, physicians travel 1 to 2 hours to outlying clinics in Georgia daily to serve these patients. Additionally, ACI offers Cardiac Research opportunities providing free medical care to patients who are eligible for study. The Mobile Health Outreach Ministry (MHOM) utilizes five mobile medical clinics that deliver medical care to neighborhoods and communities that lack access to medical care. These fully staffed doctors' offices-on-wheels provide acute and preventative services that include pediatric care, dentistry, and adult medical services. Their unique delivery model is the only one of its kind in the Northeast Florida region that provides free medical care to the area's poor and vulnerable. The MHOM regularly visits middle and high schools located in the lower socioeconomic areas to provide physicals and screenings to children. Additionally, the MHOM vehicles, in partnership with local Departments of Health, make scheduled visits to the outlying rural communities to provide primary care and secondary care, to those who lack access to medical care. As a direct result of poor access to care, these rural markets experience a higher risk of heart disease, high blood pressure, diabetes, and obesity, as well as transforming minor health issues into degenerative more complicated and costly diseases. ACI provides these services to support St. Vincent's HealthCare's mission of service to all persons with special attention to those who are poor and vulnerable. Operations and governance: - St. Vincent's Ambulatory Care has an extensive operations and support team. - ACI recently formed a physician governance council which provides monthly reports to St. Vincent's HealthCare Board of Directors. - ACI is subject to all federal and state regulations including CMS, OBRA and OSHA. - ACI participates in Medicaid, Medicare, CHAMPUS, Tricare, and/or other government-based health care sponsored health care programs Unreimbursed Services Provided to the Elderly and the Poor: In the spirit of principles adopted by Ascension Health, St. Vincent's ACI has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of ambulatory specialty care to all persons, especially the uninsured and the underserved. During the fiscal year ending June 30, 2014, approximately 57.5% of the values of services rendered were to elderly patients under the Medicare program, and approximately 7.7of the services were provided to patients under the Medicaid or Charity program. The data below indicates the importance of success to critically needed free medical care provided by St. Vincent's MHOM between July 2013 and June 2014. - More than 25,000 free adult and pediatric patient services were provided, including patient visits, health screenings, and case management, as well as outreach services such as delivering food, clothing and critically important medications to the needy. Included among those services are: - Over 4,500 patient visits and case management were completed through our Rural Outreach Ministry. - Over 4,800 patient visits and case management were provided by the Urban Outreach Ministry (Duval, Clay and Nassau counties). - Over 12,000 patient visits and case management were provided through the Pediatric Outreach Ministry, which includes over 3,700 school and sports physicals and approximately 1,200 immunizations. - More than 2,900 nutritional and dietary services that include classes, counseling and fitness training have been provided to children helping to reduce obesity and chronic diseases such as diabetes and heart disease associated. Patient Services: ACI Specialty Practices offer outpatient clinics, surgery, procedures, neurologic testing, specialized surgeries aimed to treat cancer patients, sleep studies, radiology, infusions, pulmonary function testing, hearing assessment, obstetric care and deliveries, non invasive cardiac testing and inpatient care. Additionally, ACI offers Cardiac Research, which provides procedures, tests, medications and care to patients at no charge. Cardiology offers specialized programs aimed at reducing hospital readmissions. The physicians have learned innovative medical procedures, often the first in the country that will extend patients lives or their ability to function in their day to day activities. The MHOM also provides the community with valuable health screenings, education, referrals and medications. If a patient is diagnosed or needs additional screening or follow-up care, the MHOM connects that patient with charity services within St. Vincent's HealthCare or other local non-profits to provide additional specialty services. During the fiscal year ended June 30, 2014, ACI provided 194,426 in services. Summary: St. Vincent's Ambulatory Care Inc., furthers its charitable purposes by providing a broad array of medical services with an innovative delivery method to those who are in need of healthcare, education and outreach services. ACI provides essential care to the community and offers appropriate charity services to those eligible residents who are unable to pay for their own care. ACI provides care and education to the elderly and infirm that has challenges accessing services in order to improve the overall status of our patients and our community. The care of these people who are so in need of support is the founding mission of the Daughters of Charity.
Form 990, Part VI, Section A, line 2
Many of the persons listed on Part VII have a "business relationship" with each other by virtue of employment by St. Vincent's Health related entities.
Form 990, Part VI, Section A, line 4
St. Vincent's Ambulatory Care Inc.'s bylaws have been updated to include additional clarification under the statement of purpose. Additionally, the composition of the board has been updated to include the Chief Operating Officer and the Chief Financial Officer. Finally, the dissolution paragraphs have been updated.
Form 990, Part VI, Section A, line 6
St. Vincent's Ambulatory Care, Inc. has a single corporate member, St. Vincent's Health System, Inc.
Form 990, Part VI, Section A, line 7a
St. Vincent's Ambulatory Care, Inc. has a single corporate member, St. Vincent's Health System, Inc., who has the ability to elect members to the governing body of St. Vincent's Ambulatory Care, Inc.
Form 990, Part VI, Section A, line 7b
All decisions that have a material impact to St. Vincent's Ambulatory Care, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, St. Vincent's Health System, Inc.
Form 990, Part VI, Section B, line 11
Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form to the Board, or a designated committee, to review. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions.
Form 990, Part VI, Section B, line 12c
Officers, directors or trustees, and key employees are required to complete a Conflict of Interest Attestation Statement at the time of hiring or when their service begins. Annually, the Corporate Responsibility Officer sends the Conflict of Interest Policy and Attestation Statement to all officers, directors or trustees, and key employees for completion and return within two weeks. Three separate mailings are sent out with two week deadlines to receive a maximum response. The responses from the returned Attestation Statement are organized in a spreadsheet and are carefully reviewed by the Corporate Responsibility Officer, the Chief Legal Officer, and the Chief Executive Officer. A full report is presented to the Audit Committee and any potential conflicts of interest are handled by the Committee in an appropriate manner.
Form 990, Part VI, Section B, line 15
In determining the compensation of the organization's CEO, the process, performed by Ascension Health, a related organization of St. Vincent's Ambulatory Care, Inc., included a review and approval by independent persons, comparability data and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the CEO was compared to individuals at other organizations in the area who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the Committee minutes. The individual was not present when his compensation was decided. In determining the compensation of other officers of the organization, the process, performed by St. Vincent's Health System, Inc., a related organization who paid the other officers, included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Audit Committee reviewed and approved the compensation. In the review of the compensation, the other officers were compared to individuals at other organizations in the area who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes.
Form 990, Part VI, Section C, line 19
The organization will provide any documents open to public inspection upon request.
Form 990, Part VII, Section B:
Independent Contractor Reporting: Compensation of independent contractors is paid by and reported on the Form 1096, Annual Summary and Transmittal of U.S. Information Returns, of Ascension Health EIN 31-1662309. Expenses are allocated to and reimbursed by the filing organization to Ascension Health. As such, the organization has not reported independent contractors paid on Form 990, Part VII, Section B.
Form 990, Part XI, line 9:
Transfers from Affiliates 61,425,968. Unrestricted Deferred Pension Cost -365,523. Net Assets Released from Restrictions -1,161,998.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.