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
SU CLINICA FAMILIAR INC
Employer identification number
74-2357970
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.") ....
9,263,858
9,868,849
16,915,436
9,748,240
9,485,698
55,282,081
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
9,263,858
9,868,849
16,915,436
9,748,240
9,485,698
55,282,081
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.
55,282,081
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..
9,263,858
9,868,849
16,915,436
9,748,240
9,485,698
55,282,081
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
148,959
97,921
66,949
22,824
5,441
342,094
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.)..
308,273
279,362
128,957
477,982
1,194,574
11
Total support (Add lines 7 through 10).
56,818,749
12
Gross receipts from related activities, etc. (see instructions)
..................
12
96,751,295
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
97.300 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
97.370 %
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
SU CLINICA FAMILIAR INC
Employer identification number
74-2357970
Return Reference
Explanation
FORM 990, PART III, LINE 4A
SU CLINICA'S COMMITMENT TO A HEALTHY SOCIETY INCLUDES PARTICIPATION IN A VARIETY OF DIFFERENT PROGRAMS, AS LISTED HERE. -DIABETES COLLABORATIVE - A NATIONAL PROGRAM TO PROVIDE PERSONALIZED CASE MANAGEMENT SERVICES TO DIABETES PATIENTS. -HEALTHY START - PROVIDES PERSONALIZED COUNSELING TO HIGH RISK MOTHERS-TO-BE. -CHILD HEALTH INSURANCE PROGRAM (CHIP) OUTREACH PROGRAM - INFORMS LOW INCOME FAMILIES ON THE BENEFITS OF ENROLLING CHILDREN IN THE STATE CHIP PROGRAM. -REACH OUT AND READ - MAKES EARLY LITERACY PART OF PEDIATRIC PRACTICE BY PROVIDING BOOKS TO CHILDREN WHOSE FAMILIES HAVE LIMITED RESOURCES AND BY PROVIDING READING MENTORS IN OUR PEDIATRIC WAITING ROOM. -PATIENT CENTERED MEDICAL HOME (PCMH) - SU CLINICA FAMILIAR HAS TWO LEVEL 3 PCMH AT ITS BROWNSVILLE, TEXAS AND RAYMONDVILLE, TEXAS LOCATIONS. THE ORGANIZATION IS IN PROGRESS IN OBTAINING ACCREDITATION FOR TWO OTHER LOCATIONS. -ACCOUNTABLE CARE ORGANIZATION (ACO) - SU CLINICA FAMILIAR IS ENGAGED IN AN ACO WHICH IS CHARACTERIZED BY A PAYMENT AND CARE DELIVERY MODEL THAT SEEKS TO TIE PROVIDER REIMBURSEMENTS TO QUALITY METRICS AND REDUCTIONS IN THE TOTAL COST OF CARE FOR ITS MEDICARE PATIENT POPULATION. THE ACO IS ACCOUNTABLE TO THE PATIENTS AND THE THIRD-PARTY PAYER FOR THE QUALITY, APPROPRIATENESS AND EFFICIENCY OF THE HEALTH CARE PROVIDED. -DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) 1115 WAIVER THE CLINIC EXPECTS THAT THE USE OF ELECTRONIC MEDICAL RECORDS, HEALTH INFORMATION EXCHANGE, PATIENT CENTERED MEDICAL HOME AND COORDINATION WITH THE HOSPITAL WILL LEAD TO A PERCENTAGE REDUCTION IN THE NUMBER OF ADULT PATIENTS WITH TYPE 1 OR 2 DIABETES WHOSE HBA1C IS ABOVE 9.0%, OTHERWISE KNOWN AS POOR CONTROL. -RETINOPATHY SCREENING -SU CLINICA FAMILIAR PARTICIPATES IN A DIABETIC RETINOPATHY SCREENING PROGRAM WHICH INVOLVES A UNIQUE PARTNERSHIP AMONG SU CLINICA FAMILIAR, METHODIST HEALTHCARE MINISTRIES AND LOCAL SPECIALISTS. THE INITIATIVE IS DESIGNED TO EXPAND THE MEDICAL HOME MODEL TO INCLUDE IN-HOUSE RETINOPATHY SCREENING IN COMBINATION WITH VOUCHERS FOR FOLLOW-UP SERVICES WHICH WOULD RESULT IN GREATER ACCESS TO CARE FOR UNINSURED DIABETIC PATIENTS IDENTIFYING POTENTIAL SHORT TERM OR LONG TERM VISION COMPLICATION DECREASING HEALTH CARE COSTS AND INCREASING PATIENTS' QUALITY OF LIFE. -EXPANDED PRIMARY HEALTH CARE-THE DSHS EXPANDED PRIMARY HEALTH CARE(EPHC) PROGRAM PROVIDES PRIMARY, PREVENTIVE AND SCREENING SERVICES TO WOMEN AGE 18 AND ABOVE WHOSE INCOME IS AT OR BELOW 200 PERCENT OF THE FEDERAL POVERTY LEVEL (FPL). OUTREACH AND DIRECT SERVICES ARE PROVIDED THROUGH COMMUNITY-BASED CLINICS UNDER CONTRACT WITH DSHS. COMMUNITY HEALTH WORKERS (CHWS) WILL HELP ENSURE WOMEN ACCESS THE PREVENTIVE AND SCREENING SERVICES APPROPRIATE TO THEM. -HRSA OUTREACH AND ENROLLMENT PROGRAM - EXPAND CURRENT OUTREACH AND ENROLLMENT ASSISTANCE ACTIVITIES AND FACILITATE ENROLLMENT OF ELIGIBLE HEALTH CENTER PATIENTS AND SERVICE AREA RESIDENTS INTO AFFORDABLE HEALTH INSURANCE COVERAGE THROUGH THE HEALTH INSURANCE MARKETPLACES, MEDICAID, OR THE CHILDREN'S HEALTH INSURANCE PROGRAM. -INNOVATIONS IN CARE GRANT PROGRAM - THIS PROJECT REPRESENTS A COMMUNITY BASED INTERVENTION DESIGNED TO TEST THE EFFECTIVENESS OF IN-HOUSE MEDICATION THERAPY MANAGEMENT SERVICES PROVIDED BY A CLINICAL PHARMACIST IN A COMMUNITY HEALTH CENTER SETTING WITH A LARGE HISPANIC POPULATION. THE CLINICAL GOAL OF THE PROJECT IS TO DECREASE THE PERCENTAGE OF DIABETIC PATIENTS WITH HBA1C IN POOR CONTROL (HBA1C >9%). THE FINANCIAL GOAL IS TO ACHIEVE COST SAVINGS THROUGH A DEMONSTRATED DECREASE IN RELATED EMERGENCY ROOM VISITS.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE CHIEF FINANCIAL OFFICER REVIEWS THE 990 AND PRESENTS IT TO THE CHIEF EXECUTIVE OFFICER FOR SECONDARY REVIEW. A BOARD OF DIRECTORS MEETING IS THEN HELD FOR PRESENTATION AND APPROVAL OF THE RETURN PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
ALL DIRECTORS AND EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST REVIEW ANNUALLY. THE FORM CLEARLY STATES THAT THEY COMPLY WITH THE POLICY. THE CENTER REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY.
FORM 990, PART VI, SECTION B, LINE 15
A SALARY RANGE IS PREPARED AND APPROVED BY THE BOARD OF DIRECTORS. THIS SALARY RANGE IS COMPRISED OF INFORMATION OBTAINED FROM OTHER COMMUNITY HEALTH CENTERS AND THE LOCAL MARKET FOR THE CHIEF EXECUTIVE OFFICER. A SURVEY OF THE MAJOR COMMUNITY HEALTH CENTERS IS COMPILED USING THE BUDGET OF THE CENTER AS A KEY INDICATOR. THIS INFORMATION IS PRESENTED TO THE CHAIRMAN OF THE BOARD. THE BOARD, VIA EXECUTIVE SESSION, USES THIS INFORMATION TO DETERMINE THE CEO'S SALARY. IN ADDITION, THE BOARD REVIEWS THE SALARIES OF ALL INDIVIDUALS OVER $100K.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES THE CONFLICT OF INTEREST POLICY, ALL GOVERNING DOCUMENTS, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 9:
CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 269,341.
FORM 990, PART XII, LINE 2C:
THE ORGANIZATION HAS A COMMITTEE RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.