Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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 VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2019 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2019 |
(iii) Distributable Amount for 2019 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2019 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2019: | ||||
| a From 2014....... | ||||
| b From 2015....... | ||||
| c From 2016....... | ||||
| d From 2017....... | ||||
| e From 2018....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2019 distributable amount | ||||
|
i
Carryover from 2014 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2019 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2019 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2020. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2015..... | ||||
| b Excess from 2016..... | ||||
| c Excess from 2017..... | ||||
| d Excess from 2018..... | ||||
| e Excess from 2019..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | 19009572 |
| Software Version: | v1.00 |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part III, Line 2 | During 2019, Saratoga Regional Medical PC (SRM) started operating a Nephrology service center in Glens Falls (GF Nephrology). GF Nephrology offers employs the most advanced diagnostic techniques to identify, develop a treatment plan, and manage kidney disease. |
| Form 990, Part III, Line 3 | During 2019, Saratoga Regional Medical PC (SRM) transferred its Adirondack Urgent Care (ADK UC) services to Saratoga Hospital, its controlling entity. ADK UC was renovated during 2019 in order to become New York State Department of Health, Article 28 certified. As a result of becoming Article 28 certified with New York State, this service was required to be part of Saratoga Hospital filing and structure. |
| Form 990, Part VI, Section A, Line 6 | Saratoga Regional Medical, PC (SRM) is a captive professional corporation. In order to ensure that SRM is operated exclusively for charitable purposes and in concert with the mission of Saratoga Hospital (Hospital), the Hospital retains control over SRM's governance through a Shareholder Control Agreement (SCA). The sole shareholder of SRM is the Chief Medical Officer of the Hospital. As a captive professional corporation, SRM's stock is held in nominee for only and the Hospital is the beneficial owner of the SRM stock. |
| Form 990, Part VI, Section A, Line 7a | The SCA referenced in the disclosure for Form 990, Part VI, Section A, Line 6 requires that the sole shareholder vote the shares as directed in writing by the Hospital's Chief Executive Officer for certain actions, which include election and removal of SRM directors. |
| Form 990, Part VI, Section A, Line 7b | Form 990, Part VI, Section A, Line 7b - The SCA referenced in the disclosure for Form 990, Part VI, Section A, Line 6 requires that the sole shareholder vote the shares as directed in writing by the Hospital's Chief Executive Officer for all material SRM governance decisions. |
| Form 990, Part VI, Section B, Line 11b | A draft of the Form 990 and any required supplemental schedules (collectively the "Form 990") is completed by Saratoga Hospital's Fiscal Services Department (Saratoga Regional Medical PC operates as an affiliate of Saratoga Hospital, Saratoga hospital is, in turn an affiliate of Albany Medical Center), with input from program personnel obtained as needed. The completed Form 990 is then reviewed by the Director, Financial Accounting and Vice President/Chief Financial Officer in order to ensure compliance with applicable instructions. The Form 990 is reviewed by an accounting firm, KPMG, as paid preparer. KPMG reviews the Form 990 to ensure accuracy of amounts reported and disclosures. Any issues or concerns identified by KPMG are raised with management, and brought to the attention of the Albany Medical Center Audit Committee of the Board of Directors of Albany Medical Center (AMC AC). The Form 990 is then presented at a meeting of the members of the AMC AC. Additionally, the SRM Directors review the return for accuracy and completeness. The complete Saratoga Hospital Board of Trustees then receives a copy of the form 990 for review prior to filing. |
| Form 990, Part VI, Section B, Line 12c | SRM maintains a Conflict of Interest (COI) policy for members of its Board of Directors and SRM officers, regardless of compensation. The policy provides clear explanations as to what family members and/or ownership interests (including non-financial interests) must be considered in assessing compliance with the policy, definitions of compensation (including non-monetary compensation) and examples of conflicts including activities that must always be avoided. On an annual basis, Saratoga Hospital (Hospital) undertakes a conflict of interest disclosure questionnaire process. All members of the Hospital's Board of Directors, management, and certain non-management employees are required to complete and file the questionnaire with the Hospital's Chief Compliance Officer. The Directors and officers for SRM are Hospital employees, the Hospital is the controlling entity for SRM, and all SRM purchases are transacted through the Hospital's purchasing processes. As a result of these factors, the Hospital's COI disclosure process is leveraged to conduct a COI review for SRM as well. Inquiries included on the questionnaire are designed to allow respondents to provide yes/no answers that will allow a determination to be made as to whether any non-compliance with the applicable conflict of interest policy has occurred, or whether there are any situations that may require further investigation. Responses to the questionnaires are tracked by the Hospital's Chief Compliance Officer and are reported to the Hospital's Board of Directors. On an annual basis the Hospital's Fiscal Services department reviews all responses submitted by all respondents in order to determine whether any COI disclosures require consideration for Form 990 reporting. The COI questionnaire includes a section where respondents are asked, for any person or entity that has done business or may do business with the Hospital, to provide names of any external entities they have interests in or are employed by. COI respondents are also required to disclose names of relatives and entities those relatives have interest or are employed by if any potential conflicts may exist. Additionally, if a potential conflict is known of, but not disclosed on the questionnaire, these persons/entities are also identified by SRM management. Any persons or entities disclosed in this area or otherwise deemed to be potential conflicts are referenced against the Hospital's accounts payable systems and its related entities in order to determine whether business was transacted with any of the disclosed entities during the past year. Materiality of any transactions identified is assessed and a determination is made as to whether the transaction of business with any of these entities was made in accordance with SRM's conflict of interest policy and the Hospital's purchasing policies (ex. competitively bid, removal of the conflicted person from the decision-making process). |
| Form 990, Part VI, Section B, Line 14 | Saratoga Hospital (Hospital), a related organization, has a written document retention and destruction policy to which Saratoga Regional Medical, P.C. (SRM) is subject to, as the Hospital maintains control over SRM's structure, strategic, financial and non-medical operational and decision making processes. |
| Form 990, Part VI, Section C, Line 19 | SRM governing documents, conflict of interest policy, and financial statements are available to the public upon request. |
| Form 990, Part IX, Line 11g | $6,860,981 - Salary and Benefits of employees leased from Saratoga Hospital. $494,911 - Other Professional Fees |
| Form 990, Part XII, Line 2c | The Board of Trustees of Saratoga Hospital (Hospital), a related organization, has a Finance Committee that holds responsibility for oversight of the annual audit of the Hospital and all Hospital-related related entities, which includes SRM. |
| Software ID: | 19009572 |
| Software Version: | v1.00 |