2023-11-14T12:09:43-06:00 2022-12-31 990 2022-01-01 815300614 FORSYTH COMMUNITY PCC LLC FORS 3362772411 650 N HIGHLAND AVE 120 WINSTON SALEM NC 27101 RICHARD LORD BOARD CHAIR 3362772411 2023-11-14 RICHARD LORD 999009999 0 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z HIGHLAND AVENUE PRIMARY CARE CLINIC RICHARD LORD MD 650 N HIGHLAND AVE 120 WINSTON SALEM NC 27101 181695 0 X N/A X LLC 2016 NC FORSYTH COMMUNITY PCC, LLC IS A JOINT VENTURE FORMED IN 2018 BETWEEN FORSYTH MEMORIAL HOSPITAL, INC. AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER TO PROVIDE HEALTHCARE SERVICES TO FORSYTH COUNTY, NC. 8 8 0 8 0 0 0 0 242723 179338 511 2342 20 15 243254 181695 0 0 0 0 0 0 0 0 0 1439334 1041505 1439334 1041505 -1196080 -859810 500435 736528 823760 319663 -323325 416865 X SEE SCHEDULE O 0 0 956655 179353 FORSYTH COMMUNITY PCC, LLC ("FCPCC") IS A JOINT VENTURE FORMED IN 2018 BETWEEN FORSYTH MEMORIAL HOSPITAL, INC. AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER TO PROVIDE HEALTHCARE SERVICES IN FORSYTH COUNTY, NC. FCPCC OPERATES A COMMUNITY CARE CLINIC, LOCATED IN A HISTORICALLY UNDERSERVED COMMUNITY, AND PROVIDES HEALTHCARE SERVICES AT NOMINAL FEES. 956655 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 NC X MELVINIA MCMILLAN 3367184770 650 N HIGHLAND AVE WINSTON SALEM NC 27101 X X AMANDA BURTON TREASURER 0.20 0.00 X X 0 0 0 LIA ERICKSON MD TRUSTEE 0.20 0.00 X 0 0 0 JOYCE MOUNCE SECRETARY 0.20 0.00 X X 0 0 0 PAULA BIRD TRUSTEE 0.20 0.00 X 0 0 0 RICHARD LORD MD MEDICAL DIRECTOR/CHAIR 0.20 0.00 X X 0 0 0 JOHN MANN MD VICE CHAIR 0.20 0.00 X X 0 0 0 CHRISTOPHER PROUTY TRUSTEE 0.20 0.00 X 0 0 0 STEVEN SCOGGIN TRUSTEE 0.20 0.00 X 0 0 0 0 0 0 0 0 0 0 WAKE FOREST UNIVERSITY BAPTIST MEDICAL C MEDICAL CENTER BLVD WINSTON SALEM NC 27157 PHYSICIAN SERVICES 412636 NOVANT MEDICAL GROUP INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 MANAGEMENT AND ADMIN SVCS 306200 2 NET PATIENT REVENUE 621111 175541 175541 RENTAL INCOME 531120 3297 3297 VALUE BASED INCENTIVE 900099 500 500 179338 2342 2342 MISCELLANEOUS REVENUE 900099 15 15 15 181695 179353 0 2342 X 11404 11404 708157 706949 1208 265 265 42786 8400 34386 8450 8450 89742 89742 1304 1304 108022 107765 257 23777 228 23549 MEDICAL SUPPLIES 14093 14093 BILLING FEES 12110 12110 PHARMACEUTICALS 11453 11453 OTHER SUPPLIES 2476 2350 126 7466 5656 1810 1041505 956655 84850 0 14619 350435 55186 63485 772549 449941 430630 322608 500435 736528 251639 101045 572121 218618 823760 319663 X -323325 416865 -323325 416865 500435 736528 X -859810 1600000 X 0 1 X 1 0 X 1686 63491 133232 242743 179353 620505 1686 63491 133232 242743 179353 620505 0 0 0 620505 3045 1826 274 511 2342 7998 3045 1826 274 511 2342 7998 4731 65317 133506 243254 181695 628503 0.98730 0.01270 X 548898 343010 205888 223651 106931 116720 322608 0 THIRD PARTY PAYABLE 4621 DUE TO AFFILIATES 213997 218618 X PART X, LINE 2: THE COMPANY IS INCLUDED IN THE NOVANT HEALTH, INC. CONSOLIDATED FINANCIAL STATEMENTS UNDER GENERALLY ACCEPTED ACCOUNTING STANDARDS, BUT DOES NOT MEET THE CONTROL REQUIREMENTS TO BE CONSIDERED A RELATED ENTITY FOR FORM 990 REPORTING. NOVANT HEALTH IS REQUIRED TO EVALUATE UNCERTAIN TAX POSITIONS. THIS EVALUATION INCLUDES A QUANTIFICATION OF TAX RISK IN AREAS SUCH AS UNRELATED BUSINESS TAXABLE INCOME. THIS EVALUATION DID NOT HAVE A MATERIAL EFFECT ON THE COMPANY'S CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2022 AND 2021. FORM 990, PIII, L1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT ACTIVITIES THE PROMOTION OF HEALTH FOR THE BENEFIT OF THE COMMUNITY IS A CHARITABLE PURPOSE. FEDERAL HEALTH CARE REFORM AND OTHER CHANGES RELATING TO THE PROVISION OF HEALTH CARE SERVICES HAVE MADE IT INCREASINGLY CRITICAL FOR HOSPITAL SYSTEMS AND THEIR CONSTITUENT HOSPITALS TO BE ABLE EFFECTIVELY TO ALIGN WITH OTHER HEALTH CARE PROVIDERS AND PHYSICIANS AS THEY ASSUME A GREATER ROLE IN PROVIDING CARE FOR IDENTIFIED AT-RISK POPULATIONS. FORSYTH COMMUNITY PCC, LLC IS A JOINT VENTURE FORMED IN 2018 BETWEEN FORSYTH MEMORIAL HOSPITAL, INC. ("FMH") AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER ("WAKE") TO PROVIDE HEALTHCARE SERVICES IN FORSYTH COUNTY, NC. ACCESS TO CARE IS REGULARLY IDENTIFIED AS A SIGNIFICANT AND CRITICAL NEED IN OUR COMMUNITY HEALTH NEEDS ASSESSMENTS AND ADDRESSING IT IS CRITICAL TO SUSTAINING A HEALTHY COMMUNITY. THE SAME CAN BE SAID FOR AFFORDABILITY. AFTER EXTENSIVE DUE DILIGENCE AND IN LIGHT OF THEIR COMPLEMENTARY MISSION AND VALUES, FMH AND WAKE DETERMINED THAT THEY COULD WORK TOGETHER TO ADDRESS THESE ISSUES BY CREATING THIS JOINT COMMUNITY CARE CLINIC, LOCATING IT IN A HISTORICALLY UNDERSERVED COMMUNITY, AND PROVIDING HEALTHCARE SERVICES AT NOMINAL FEES. THE CLINIC IS COMMITTED TO ENSURING ACCESS TO HIGH-QUALITY, AFFORDABLE, COMPREHENSIVE HEALTHCARE FOR ALL RESIDENTS OF FORSYTH COUNTY, REGARDLESS OF THEIR INSURANCE STATUS OR THEIR ABILITY TO PAY. FORM 990, PART VI, SECTION A, LINE 2 FORM 990, PART VI, SECTION A, LINE 2: FAMILY AND/OR BUSINESS RELATIONSHIPS BUSINESS RELATIONSHIP RICHARD LORD AMANDA BURTON STEVEN SCOGGIN FORM 990, PART VI, SECTION A, LINE 3 FORSYTH COMMUNITY PCC, LLC ("FCPCC") HAS DELEGATED MANAGEMENT OF ADMINISTRATIVE SUPPORT SERVICES. THE MANAGER IS RESPONSIBLE FOR CERTAIN MANAGEMENT AND ADMINISTRATIVE SERVICES INCLUDING NON-CLINICAL OPERATIONAL OVERSIGHT, UTILIZATION REVIEW AND QUALITY ASSURANCE, MARKETING AND BRANDING, FINANCIAL MANAGEMENT INCLUDING ACCOUNTING, BUDGET PREPARATION, BILLING AND COLLECTIONS, PROVIDER CONTRACTING AND CREDENTIALING, FACILITIES AND INFORMATION TECHNOLOGY MANAGEMENT, REGULATORY AND RISK MANAGEMENT, CONTRACTING/PURCHASING SERVICES, AND RECRUITMENT/PERSONNEL STAFFING SERVICES. NO CURRENT OR FORMER OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES OR HIGHEST COMPENSATED EMPLOYEES WERE COMPENSATED BY THE MANAGEMENT COMPANY FOR ANY SERVICES PROVIDED TO FCPCC DURING THE YEAR. FORM 990, PART VI, SECTION A, LINE 6 FORM 990, PART VI, SECTION A, LINE 6: CLASSES OF MEMBERS OR STOCKHOLDERS THE ORGANIZATION IS A LIMITED LIABILITY COMPANY WITH MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE LIMITED LIABILITY COMPANY'S MEMBERS, FORSYTH MEMORIAL HOSPITAL, INC. AND AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER, EACH APPOINT 1/2 OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE LIMITED LIABILITY COMPANY'S MEMBERS, FORSYTH MEMORIAL HOSPITAL, INC. AND AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER, APPROVE CERTAIN TRANSACTIONS AND CHANGES TO THE OPERATING AGREEMENT. FORM 990, PART VI, SECTION B, LINE 11B THE RETURN WILL BE REVIEWED BY THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO ALL TRUSTEES INCLUDING MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS. WITH RESPECT TO PARTICULAR TRANSACTIONS THAT COME BEFORE THE BOARD, THE CONFLICT OF INTEREST POLICY WOULD BE FOLLOWED. THE POTENTIAL CONFLICT OF INTEREST WOULD BE DISCLOSED BY THE BOARD MEMBER BEFORE A VOTE ON THE TRANSACTION AND THE REST OF THE BOARD WOULD DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE REST OF THE BOARD DETERMINED THAT A CONFLICT OF INTEREST EXISTED THEN THE BOARD MEMBER WITH THE CONFLICT OF INTEREST WOULD NOT PARTICIPATE IN THE DELIBERATIONS AND VOTE. FORM 990, PART VI, SECTION C, LINE 19 FORM 990, PART VI, SECTION C, LINE 19: GOVERNING DOCUMENTS DISCLOSURE NO DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VII, SECTION B: INDEPENDENT CONTRACTORS THE FILING ENTITY'S ACCOUNTS PAYABLE FUNCTION IS MANAGED BY THEIR SUPPORT SERVICES PROVIDER, NOVANT MEDICAL GROUP, INC. (NMG) AND AS SUCH, THEY DO NOT ISSUE 1099S DIRECTLY. INFORMATION REPORTED IN PART VII, SECTION B REPRESENTS THE EXPENSES PAID ON BEHALF OF THE FILING ENTITY TO INDEPENDENT CONTRACTORS OVER $100,000. FORM 990, PART IX, LINE 11G OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 9,801. MANAGEMENT AND GENERAL EXPENSES 1,208. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,009. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 284,512. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 284,512. PROFESSIONAL PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 412,636. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 412,636. FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTIONS 1,600,000.