2024-08-15T12:32:15-05:00 2023-09-30 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2022-10-01 273785445 LAKE CHAMPLAIN PHYSICIAN SERVICES PC LAKE 5185612000 75 BEEKMAN STREET PLATTSBURGH NY 12901 DR LISA MARK PRESIDENT 5185612000 2024-08-06 1 1 THOMAS J GIUFRE P00841958 3154463600 2024-08-06 2022 2024-08-08 14:25:15Z DR LISA MARK 75 BEEKMAN STREET PLATTSBURGH NY 12901 2550 0 X WWW.CVPH.ORG X 2010 NY LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. IS A PROFESSIONAL SERVICES COMPANY FORMED TO FURTHER THE CHARITABLE PURPOSES OF CHAMPLAIN VALLEY PHYSICIANS' HOSPITAL MEDICAL CENTER THROUGH PROVIDING MEDICAL SERVICES TO THE COMMUNITY. 1 0 0 0 0 0 0 0 22264 2550 0 0 0 0 22264 2550 0 0 0 0 0 0 0 0 0 86297 1258 86297 1258 -64033 1292 90276 90284 264699 263415 -174423 -173131 LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. IS A PROFESSIONAL SERVICES COMPANY FORMED TO FURTHER THE CHARITABLE PURPOSES OF CHAMPLAIN VALLEY PHYSICIANS' HOSPITAL MEDICAL CENTER THROUGH PROVIDING MEDICAL SERVICES TO THE COMMUNITY. 0 0 1258 2550 LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PROVIDES GENERAL MEDICAL SERVICES TO PATIENTS. 1258 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 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 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 1 0 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X THE ORGANIZATION 5185612000 75 BEEKMAN STREET PLATTSBURGH NY 12901 WOUTER JAN RIETSEMA MD SHAREHOLDER/MEMBER 2.00 48.00 X X 0 454136 52554 CHRISTOPHER HICKEY SVP/CFO 20.00 30.00 X 0 440560 33055 MICHELLE LEBEAU PRESIDENT/COO 2.00 48.00 X 0 607301 51434 MATEJ KOLLAR VP/CFO 2.00 48.00 X 0 212288 32115 0 1714285 169158 0 0 1 0 0 MEDICAL SERVICES 621110 2550 2550 2550 2550 2550 0 0 1101 1101 LICENSES AND TAXES 157 157 1258 1258 0 0 62631 64467 27573 25745 72 72 90276 90284 264699 263415 264699 263415 X -174423 -173131 -174423 -173131 90276 90284 1292 0 X X 0 1 X 1 0 X X 1 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER 141338471 3 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 DUE TO RELATED PARTIES 263415 263415 X PART X, LINE 2: LAKE CHAMPLAIN PHYSICIAN SERVICES, PC IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS FOR THE UNIVERSITY OF VERMONT HEALTH NETWORK. PAGES 17 AND 18 OF THE CONSOLIDATED FINANCIAL STATEMENTS CONTAIN A FOOTNOTE INDICATING THAT NO PROVISION FOR FEDERAL INCOME TAXES HAS BEEN RECORDED. 1 X X X X X 0 1 0 0 0 0 0 1 1 1 MICHELLE LEBEAU PRESIDENT/COO 0 491886 0 89938 0 25477 0 32091 0 19343 0 658735 0 0 WOUTER JAN RIETSEMA MD SHAREHOLDER/MEMBER 0 371044 0 50643 0 32449 0 33550 0 19004 0 506690 0 0 CHRISTOPHER HICKEY SVP/CFO 0 389094 0 51466 0 0 0 15250 0 17805 0 473615 0 0 MATEJ KOLLAR VP/CFO 0 199031 0 13257 0 0 0 9996 0 22119 0 244403 0 0 PART I, LINE 3 IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B DURING 2022, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER CONTINUED A COMPENSATION INCENTIVE PLAN FOR MANAGEMENT OF THE ORGANIZATION. THE PLAN SETS FORTH NUMEROUS OBJECTIVES AND GOALS (16) TO BE MET IN ORDER TO EARN AN INCENTIVE AWARD. EACH OF THE GOALS ARE AIMED AT IMPROVING THE EXPANSE OF CVPH'S SERVICE OFFERINGS, QUALITY OF SERVICE AND OPERATION, AND MEETING COMMUNITY NEEDS. ONLY ONE OF THE 16 OBJECTIVES INCLUDED IN THE 2022 PLAN IS KEYED TO NET MARGIN OF THE ORGANIZATION. THIS MEASURE IS INTENDED TO MEET THE OVERALL GOAL OF MAINTAINING THE FINANCIAL HEALTH OF THE ORGANIZATION. OTHER GOALS IN THE PLAN ARE TO IMPROVE PATIENT & EMPLOYEE SATISFACTION. PART I, LINE 7 LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PAID AWARDS TO CERTAIN MEMBERS OF UPPER MANAGEMENT (DIRECTORS, VICE PRESIDENTS, PHYSICIAN CHAIRS AND SENIOR EXECUTIVES) THROUGH ITS ANNUAL VARIABLE PAY PLAN AS THE PLAN'S PERFORMANCE MEASURES WERE MET. THE MEASURES WERE REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THESE MEASURES INCLUDED FINANCIAL, POPULATION HEALTH & QUALITY, AND OPERATIONAL RELATED METRICS. PART I, LINE 8 SALARIES AND OTHER FIXED AMOUNTS PAYABLE TO EXECUTIVES SUCH AS OFFICERS AND CERTAIN KEY EMPLOYEES ARE SET BY CONTRACTS THAT ARE NEGOTIATED AND ENTERED INTO PRIOR TO THE COMMENCEMENT OF EACH EXECUTIVES' EMPLOYMENT. THE TERMS OF SUCH CONTRACTS ARE APPROVED IN ADVANCE BY THE APPROPRIATE COMPENSATION COMMITTEE OR OTHER BOARD-AUTHORIZED BODY, WHICH OBTAINS AND RELIES ON APPROPRIATE DATA AS TO COMPARABILITY PRIOR TO MAKING SUCH OFFER, AND CONCURRENTLY DOCUMENTS ITS BASIS FOR DETERMINATION. FORM 990, PART VI, SECTION A, LINE 6 DR. WOUTER RIETSEMA IS THE SOLE VOTING MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A ACCORDING TO THE SHAREHOLDERS AGREEMENT, DR. WOUTER REITSEMA, THE SOLE SHAREHOLDER AND DIRECTOR OF LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C., IS REQUIRED TO VOTE ALL OF HIS SHARES TO ELECT, OR REMOVE, AS DIRECTORS THOSE INDIVIDUALS DESIGNATED BY THE BOARD OF DIRECTORS OF THE MEDICAL CENTER. FORM 990, PART VI, SECTION B, LINE 11B LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PROVIDES AN ELECTRONIC COPY OF FORM 990 TO EACH BOARD MEMBER PRIOR TO THE FORM BEING FILED. FORM 990, PART VI, SECTION B, LINE 12C LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. HAS A WRITTEN CONFLICT OF INTEREST POLICY AS A PART OF ITS GOVERNING DOCUMENTS. THE POLICY IS APPLICABLE TO MEMBERS OF THE GOVERNING BODY, OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION REQUIRES THAT MEMBERS HAVING A CONFLICT OF INTEREST IN A TRANSACTION RECUSE THEMSELVES OF VOTING ON THE MATTER. PROPOSED AND ONGOING TRANSACTIONS ARE REVIEWED BY APPROPRIATE GROUPS OF INDIVIUALS (COMMITTEES AND/OR LEVELS OF REVIEW) TO ENSURE THE BEST INTEREST OF THE HOSPITAL. THE ORGANIZATION SOLICITS FROM EACH MEMBER OF THE GOVERNING BODY, OFFICERS, AND KEY EMPLOYEES AN ANNUAL SIGNED STATEMENT CERTIFYING COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND SELF-DISCLOSURE OF CERTAIN INTEREST FOR EACH ANNUAL PERIOD. FORM 990, PART VI, SECTION B, LINE 15 LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. HAS A FORMAL PROCESS THAT IS USED TO DETERMINE THE COMPENSATION OF THE CEO ON AN ANNUAL BASIS. THIS PROCESS INCLUDES A COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, ENGAGING AN INDEPENDENT CONSULTANT, PERFORMANCE OF A COMPENSATION SURVEY OR STUDY, REVIEW OF OTHER ORGANIZATION'S 990 FORMS, AND APPROVAL BY THE BOARD OF COMPENSATION COMMITTEE. A WRITTEN EMPLOYMENT AGREEMENT IS ESTABLISHED SETTING FORTH THE COMPENSATION AND BENEFITS OF THE CEO. LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PAYS NON-FIXED EARNINGS BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA THAT ARE PROSPECTIVELY AGREED UPON AS GOALS FOR THE CEO. PART B: THE SAME FORMAL PROCESS NOTED IN 15(A) ABOVE IS USED TO DETERMINE THE BASE COMPENSATION OF OTHER OFFICERS. NON-FIXED EARNINGS OF OTHER OFFICERS ARE BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA AND COMPARATIVE MARKET DATA. IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN SCHEDULE J, PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION C, LINE 19 LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PARTIES DESIRING COPIES OF SUCH DOCUMENTS MUST PRESENT THEMSELVES AT THE ADMINISTRATIVE OFFICES OF LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. OR BY SENDING A REQUEST IN WRITING TO THE ADMINISTRATIVE OFFICES. THE ORGANIZATION HAS INSTRUCTIONS POSTED ON ITS WEBSITE FOR THOSE SEEKING COPIES OF DOCUMENTS. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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