HomeMy WebLinkAboutPROJECT ACCESS 1/1/08 12/31/08
Fundin re uest from Outside A
Agency: Richmond County Medical Society-Project Access
Budget Time Frame: 1/1/08 to 12/31/08
Submitted by: Rtwls p(OjtJ (\'-~~1..'Inc...
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MAR 0 3 2008
Accounting {)ep'a'trrl~Nt ..
BUDGET PREP ARA TION CHECKLIST
The following checklist is provided to assist you in preparing the required budget documentation and
must be included as part of your department's budget submittal. The Department Director must sign
the "statement of compliance" at the end of this checklist prior to budget submission.
YES NO
1. You have received all information related to your entire department. If not V
contact your Budget Analyst immediately.
2. MISSION STATEMENT ./
a. Departmental Goals and Objectives
b. Performance Measures/Managing for Results
c. Function Charts
3. ORGANIZATIONS CHART(s)
4. SUMMARY OF MAJOR ISSUES
a. Major issues identified Af.Jr
b. Brief description of each issue ~}\+
5. PROGRAM AND SERVICE INVENTORY FORMS
a. Program and Service Inv,!::ntory fams are included for all current rI)~
services
-
b. Program and Service Inventory fams are included for each Request -.!!JA-
for Additional Funding
6. EXPENSES
a. Expense Budget input (Budget Forms) ./
-
b. Input Data has been checked for accuracy V'
c. Supplementary Expense sheets included v
7. POSITION CONTROL - review all position control information
a. Verified position information f'J J 'iT
b. Updated pay information as needed ./
c. Included vacant positions projected to be filled in FY2007 "'-/'(:1.
d. Included budget for seasonal and temporary positions /VJ~
e. Positions Summaries have been completed according to instructions ~A-
f. The Position Summary and the Personnel Report agree as to the number ~~
and classification of positions
BUDGET PREPARATION CHECKLIST
YES NO
8. CAPITAL BUDGET
a. Capital Budget Request previously submitted
b. Relationship to General Fund Highlighted
rJJ~
fII!f.Y
STATEMENT OF COMPLIANCE
The budget submittal for the Department of a..
compliance with the guidelines as set forth by the Finance De
checked and verified against the above checklist.
~C:'Q f.~
Director ~
d.,. d P ,. ;;La 0 g
Date
RCMS Project Access, Inc.
2008 Officers, Board of Directors and Staff
Officers: (2 year terms) 2008-2009
President
Vice PresidentIPresident Elect
Secretary
Treasurer
Terrence 1. Cook, M.D.
Peter Payne, M.D.
Jill Haunstein, M.D.
William L. FaIT, M.D.
Board of Directors: (3 year terms) (terms to be staggered so that 1/3 is elected annually)
Terrence J. Cook, M.D., Chairman (2010)
Joseph P. Bailey, M.D. (2010)
Adair Blackwood, M.D. (2010)
Tommy Boyles (2008)
Comm. Jerry Brigham (2010)
Donnie Dunagan, M.D. (2009)
William L. Farr, M.D. (2008)
Joe Griffin, M.D. (2008)
Jill Hauenstein, M.D. (2008)
Jonathan Krauss, M.D. (2010)
Staff:
Daniel R. Walton
Stacie McGahee
Nancy Graham
Heather Palmer
Denise Mooney
Monique Lentz, M.D. (2009)
Donald H. Loebl, M.D. (2010)
Lucy Marion, Ph.D., RN (2008)
Peter Payne, M.D. (2008)
John Salazar, M.D. (2008)
Amy Sprague, M.D. (2009)
Luther Thomas, III, M.D. (2009)
Al Carr, M.D. (2010)
Ketty Gonzales, M.D. (2008)
Ram Mohan, M.D. (2010)
Executive Director
Administrator
Project Coordinator
Administrative Assistant
Case Worker (DFCS Employee)
. , .
Foon W.g
Request for T axpaye r
Identification Number and Certification
Giverorm to tile
requelier. Do not
aend to the IRS,
(l'lw. Ombllr 2007)
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r Identification Number
B1tar )'Our TIN In 1he approprtata Ix>x. TIle TIN pFm'kiild must match 1I1e ralllil qrm on Una 1 to lJl'Old
~~ 'A1lt1hOk:ln; For IndMduals. 11115 Is )'OOr IIOOIBl securtty nlJl1ber (SBI'ij. I-k:tNfier, fOr a rEElGlint
allan. sola J:fllp1etCf. er dlsregartlad enl~, 8ee1he Part I hslru=tlona on page :l For ether errtI1Ies, It IS
)'011" emplo'fer k>3nt~att:fl nlJl1ber (EI~. 1f)'OO do not have I rumbar, see Hew to gel Ii 1W on page a.
Not.. If the ao::ount IS In mOIll ihan one name, see1he Ch!ft on page41a IJ.ll:lellnBS 00 'Atloae
nulTtEr to entEr.
Certification
Uooer perallles Dfpequl'j'. I certify 1I1at:
1. Tl1e nlJl1ber ShD'",n Cfl1ll1s fcrm If> IT'o/ cctTEGt tm:payer Iderrlmcallon rumbar (or I <I'll wathg 1a 8. nulTtEr tob!lIssuEd to Illil). arK:l
2. 1111I rot su~ecl to bBCll:UP wrltfladlng tKlIIJS!l: (B} I am alelJlX from ~lwp wlthl1Oldhg. or ~) I have not bEa'l nolltlEd try iha Internal
Ril\'mue 8el'i1ce (IRS) that I am SUbject to ~k1.p WIIl1hol:ll~ as I resut of a falUIll to fE1Xlrt Blllnterest Cf d'ildends. or (c) the IRS has
octlllad me 1tlat I am no kl~er SUbject to ~~ 'A1lt1hOk:lrg. !lid
3. 1111I a U.s. cilium or other U.S. pllBOn (dEl'l1ed below).
certlflcailCfllnslrucllons. You must CfCGS out Item 2 alx7ie If )'Ou hm'eb!len no1lnEd try iha IRS that )'00 are currenl~ sul;1Ect to bBCll:up
y,1thh:lldhg because )~u hm'e faled to Illpcrt allnlelllst !lid dNk>300S 00 )'OOrtD IllIum. For real 83l:ate tI'!f1Sa.ctlCflS, Item 2 does not ~If.
Fer matga;je Interellt FXlId. acqul'altt:fl or abandonmerrt Df secured propErly, carKlillL!llon of dell't, COn1rtxrtlCflS to an lool\'KiIal re1Jllllllilnt
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pfCYi1de )'oor OOTect TIN. Bee the Instru:llons Cfl page 4-
~61p11nor l) ~ /)
Hwo U.ltpiifSOR .. <1..---' I<. .
General Instructions
Sedion merencea are to 1M lrt€fTlalReverue Code unlEea
otherMae I"Dted.
Purpose of Form
A~, wtlo ill req.Jired to fie III inforrnSliCflr&1Um with tll3
IHS must romn )'OOr 000'eCt tmlpayef Dernificsttlln numbEf (TIN)
to.rt. for example, income paid to you. real eatatll
tl'tl1eactiorl9. m::ngsgeintEfeetyou paid. soqliation or
abllldonment of IlEClftdproperty. c!f1OellBlion 01 debt. or
contribuliona you made to IIri 1M
Uae FoonW-9 onlyif)'OO Bill a ua pEf9Cfl ~nduding a
reeident elen). topl'O'li.. '09)'OOr lXIITect TIN to 1M pereon
requee1ing it !the I'a:lUBetEfl and, whon ~icabla; to:
1. O:!rtify that tho TIN .yetI CC9!l.f ivi~ is correct (or yeti <<e
waiting for a number 10 be iSElUedj.
2.. O:!rtify that you nnot eubject to backLp wilhholdirg. Cf
3. Claim exemption. from... 00. clwp witltiolding !fyou are Ii UA
exempt payee. If~icS:le. yoo areliao certll)'i~ that ea a
UB. ~. }'OOr sl~e l'lI1are of lUTj pattft9l'8hip i100me from
e U.s. tm or D1J9i1eae is not slbjact to 1M wittmldirg tax on
foreignpsrtner&' share d etfsctivelyoonnect!ld incorTllt.
Note. If e requester gNE<!! you II form o1hef thanFoon W-Id to
I'lKlUBI!t~r TIN. yoomuet use the I'a:lUBetEf'e fumI if it ill
aJb9tantialy aimHEr to thill Form W.lJ.
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Oefllritioo of a us. pel'SOn.For federal tiIX pu~. you are
conaklerid a UA pEf9Cflif you Ere:
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. A partnership, ocrporstion. oompany. or aesociation ~ or
org!llized in the Unite.d StatEe Cf undar the .ltrNs .of the United
Sts1ea.
. Nt estate (othEf 1Mn a foreign ~l. Cf
. A domeetic trust (as defined In Regtlatiooa seetion
301,7701-71,
Special rulM for pm:inersbips. Ptrtl1elltlipt. that oonduct a
trade or buai1eall In the United States Ere generally teqJired to
pa'J e witItIoldirg tax on any foreign partnel8' mare of inOCfll9
f1'OO'l sooh buaineea. FurthEf, in oertsin c:aese wtlere a Foon W-Id
hea not beenftlCaved, a partnership illl'a:llired to p<<l9ume Ihst
aplltner ill a foreign pEf9Cfl, and pay 1he Wi1hholdi~ tax.
Th~ if )'00 8Ill a !J.a pEf8Ol1 that ie a partner n a
partnel8tip cordooti1g Ii trD or buainetlS in the United Statile..
pro'lide FOOD W-Id to tMplltnerehip to eetttXieh yoor U.s.
B1EItue and a.void withhoking on )011" mare of partnerahp
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The per80n who gMleFoon W.lJ to 1hepartnership for
ptJrpoeea of satatItShing ita UA status and IillIODi1g with~ding
onn allocable share d flirtnoome from 1he plltllEf'llhip
cof'IiiJctinge trade or businetlS in 1ha United Statile i& in 1he
followirg .caeee;
. The UA owner of a d~arded entity a'ld not 1he entity,
ClIl. 1\1:). 10231;( FDITlI W..Q (RW. 10-2001)
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This AGREEMENT made and entered this 4th day of January, 2008, between Augusta,
Georgia, acting by and through the Augusta-Richmond County Commission, a political
subdivision of the State of Georgia (hereinafter refeITed to as "Augusta" or "County"), and the
Richmond County Medical Society-Proiect Access., (hereinafter refeITed to as the
"Organization" or "AGENCY"); WITNESSETH:
WHEREAS, the Augusta-Richmond County Commission desires to contract
with the above named Organization to PROVIDE FUNDS FOR THE OPERATIONS OF
THE AGENCY
Whereas the amount of $450,000 is now available for use by AGENCY., according to
the GENERAL FUND BUDGET ADOPTED ON DECEMBER 6, 2007;
NOW, THEREFORE, for and in consideration of the mutual covenants and
agreements between the parties, it is agreed as follows:
The County agrees to appropriate the following sums to the Organization for the
purpose of: Project Access $450,000.00
The Organization agrees to use such funds that it may receive, pursuant to this
Agreement, solely and exclusively for the above described Project; said Project, including the
Project Budget, is more specifically described at "Exhibits" attached hereto and incorporated
herein.
In consideration of the disbursement of said funds, AGENCY shall observe all
conditions that the law imposes on the use of said funds, which shall include, but not be
limited to, the following
1. The agency shall provide the county with a narrative description of the program and a
detailed program budget. The budget should include all funding sources that the
agency anticipates receiving.
2. The Agency shall provide the following information as part of the narrative:
a. Mission Statement
b. Performance Budget Overview
c. Budget Request
d. Summary
3. The Agency shall complete the following forms as part of the budgeting process:
a. Budget Preparation Checklist
b. Agency / Joint Funding Budget Request (Form AJ)
c. Agency / Joint Funding Budget Request Payroll Costs (Form AJ-1)
d. Copy of Agencies most recent financial statements.
4. The agency shall have an annual audit performed by an independent CPA Firm. The
Agency should specify the County as a funding source. The agency shall provide the
County a copy of the audited financial statements within 30 days of delivery of the
audit by the contractor. Said reports shall be delivered to Augusta Finance
Department, Municipal Building Augusta, GA 30911 to the attention of Ms. Donna
Williams, Finance Director or her Designee.
S. The agency shall also submit a completed form W -9 to Augusta Finance Department.
AUGUSTA-RICHMOND COUNTY COMMISSION
By: U ~-f
M ..-.,,~--....:. '.. -'t'T',
ayor ...,;,'" ~.~U:lt'10,V' \'.1
~-i!. /' . . J'\ .. r
,A,~j':;'.:~~ +......of'.....j'..,~~. ':~J";'
::~ ..:)". ..... -"" (..~. ~)
ATTEST: .of .~.... '. ";'. ~
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1'1.),: ~..,~
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By: ,
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.
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I';. b ....r.i.".'...,;o>..._~:._~..........- t,.: ~:r
'J.~. ~o;;~.t?::
Clerk ofCollimj.ssion ~e.'.:F
: ~b .....(f-~C)... ~,~..:
.,~,:;~ GeORG1.~ ~'-:f;1'
'~'-I:" ~~';f\~_~~?~7~;";""'-'
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ORGANIZATION: g<:..MS ~(D0e.J.. (jc.c.e~-, Tnc.
AGENCY
By: Mc'(J l. b
As its G'Ytt..L\.~~"1L t5ire.J-lf"
ATTESL--v...
1Jfltt6 / J'L~~
As its ad~'i1;s-lrA.-fvr'
AUGUSTA, GEORGIA
FY 2008 BUDGET
I FUND: I
DEPARTMENT
C9~f;o...t -
MISSION STATEMENT:
I 0 e ~ \-Q.. \0 \\ s n r co..o't A c.c..c n to Q.. pp..-o (>t''' Q. h.. J n \~h
Q....... \ ~ \- Y \-\eo. f ~ Ca (" q.. Co ^ 0 ( t..lo.. \- ~ ~ e...~ V \ ,~. oJ ~ ~ c.
lJ,~ \ (H~ (~ J I Q\..:) + 0 (V\ 0 d...rca ~ c... -:Lt\c.cr-. ..... ~ 1'1 k. or
(l..c.h (\I\~ td\.\r'\~ c:;.s a1'\ i ~ \-c.~n. \ CoM PfM-'n.}. o~ H.-\e.
e~ M"".,; \-7') \)JuC411 h~~ {~c.a"'-e... Sys~c,!N\.
BUDGET GOALS FY 2008:
~
Ie (Jf'O\(\de., CltL~~~ to c;.aL:~ neQ.(~ (phy~iU"~ t-
K.o~v~k.L.) SU\lI'C~S to ~ unint'vft.d I
, . 0\..) 1-0 Mod,,~ ~ e..
\ ~ ~c... J VI R"c.h t\\ d'\.o t fl"".r\ ~y .
2006 2007 2008 2008
ACTUAL BUDGET REQUEST BUDGET
SUMMARY OF EXPENDITURES
AND APPROPRIATIONS s-q\.3(o( 4-1'1', ~,~ <.f?k, '500 't "?(p~ \00
TOTAL AUTHORIZED 'f + 'f c.t
POSITIONS
Augusta, Georgia
Agency/Joint Funding Budget Request
2008 Budget Worksheet
Form
(AJ)
Fund No: General
Department No. & Name: RCMS Project Access, Inc.
Account No.:
2006 2007 2008
Expenditures Actual Budget Request
Salaries & Wages (Sch. B-2) $ 113,720 $ 118,500 $ 115,000 $ (3,500) -3%
Personnel Services $ 33,280 $ 36,000 $ 36,000 $ 0%
Support Services $ 21,662 $ 20,117 $ 25,000 $ 4,883 24%
Repairs & Maintenance $ $ $ $ 0%
Materials & Supplies $ 15,995 $ 7,851 $ 16,500 $ 8,649 110%
Public Works $ $ $ $ 0%
Other Charges $ $ $ 3,000 $ 3,000 100%
Capital Equipment $ 4,313 $ 2,574 $ 10,500 $ 7,926 308%
Other: $
Patient Prescriptions $ 358,992 $ 183,548 $ 208,000 $ 24,452 13%
Legal & Accounting $ 5,114 $ 3,180 $ 4,000 $ 820 26%
Telephone $ 1,749 $ 1,942 $ 2,500 $ 558 29%
Rent $ 15,000 $ 15,500 $ 16,000 $ 500 3%
Support To Miracle Making Ministires $ 21,536 $ 25,000 $ $ (25,000) -100%
Total Expenditures $ 591,361 $ 414,212 $ 436,500 $ 22,288 5%
Source of Revenue
Augusta $ 400,000 $ 450,000 $ 450,000 $ 0%
United Way
State of Georgia
U.S. Government I Agencies
Other $ 1,000 $ 1,000 $ $ (1,000) -1 00%
Total Revenues
$
401,000 $
451,000 $
450,000 $ (1,000)
0%
Revenue Over Expenditures
$ (190,361) $
36,788 $
13,500 $ . (23,288)
-63%
Fund No: General
Augusta, Georgia
Agency/Joint Funding Budget Request
Payroll Costs
2008 Budget Worksheet
Account No.:
Department No. & Name: RCMS Project Acces, Inc.
Employee Name/Position
Daniel Walton, Executive Director
Stacie McGahee, Administrator
Nancy Graham, PIT, Project Coordinator
James Lyle, PIT, CEO
Heather Palmer, PIT, Admin. Assist.
Total
2006
Actual
$ 48,000
$ 32,000
$ 15,000
$ 18,720
$
2007
Budget
$ 50,000
$ 33,000
$ 15,500
$ 20,000
$
Form
(AJ-1)
$ 113,720 $ 118,500 $115,000 $ (3,500)
Present GROSS ANNUAL SALARY regardless of funding source
%
2%
3%
-3%
-100%
100%
-3%
RCMS PROJECT ACCESS, INC.
5 YEAR COMPARATIVE INCOME STATEMENT
RICHMOND COUNTY
AS OF 12/31/2007
2003 2004 2005 2006 2007
REVENUE
Donated Care/Services/Rx
Physician Services (primary and specialty) 117,207 201,117 269,765 193,157
Hos ita I Services incl. labs & xra s 741,687 763,483 1,047,483 889,489
Doctors Hospital 105,388 . 111,093 62,194 . 37,47.1
MCG 4;535
Trinity Hospital .248,486 12,239 1,975 > 2,066
University Hospital 383,278 . . . 639,770 . 983,314>. .849,953
Walton. Rehab 381
Donated Care/Services-30906 Clinic 12,000 12,000
Donated Care/Services-30901 Clinic 12,000 12,000
Donated Care/Services-St. Vincents DePaul 6,000 6,000 6,000 6,000 6,000
Medical Director 18,000 18,000 18,000 18,000 12,000
RCMS Management Support 12,000 12,000 12,000 12,000 9,000
Rx (discount frpm wholesale - 15%) 22,497 32,033 35,384 53,849 27,532
Pharmacy dispensing/counseling fees ($5/Rx filled) 10,092 14,356 38,120 55,525 34,165
Total Donated Care/Services/Rx 565,061 965,282 1,074,104 1,462,622 1,171,344
Total Grants/Appropriations 450,000 450,000 400,000 401,000 451,000
TOTAL REVENUE 1,015,061 1,415,282 1,474,104 1,863,622 1,622,344
EXPENSE
Care/Services/Rx Provided
Physician Services (primary and specialty) 106,795 117,207 201,117 269,765 193,157
Hospital Services (incl. labs & xrays) 365,677 741,687 763,483 1,047,483 889,489
Donated Care/Services-30906 Clinic 12,000 12,000
Donated Care/Services-30901 Clinic 12,000 12,000
Donated Care/Services-St. Vincents DePaul 6,000 6,000 6,000 6,000 6,000
Medical Director 18,000 18,000 18,000 18,000 12,000
RCMS Management Support 12,000 12,000 12,000 12,000 9,000
Rx (discount from wholesale - 15%) 22,497 32,033 35,384 53,849 27,532
Pharmacy dispensing/counseling fees ($5/Rx filled) 10,092 14,356 38,120 55,525 34,165
Total Donated Care/Services/Rx 565,061 965,282 1,074,104 1,462,622 1,171,344
Prescription Medication
Prescription Medication 89,987 128,130 235,892 358,992 183,548
Total Prescription Medication Related 89,987 128,130 235,892 358,992 183,548
(number of grescrip,tions filled) 2,523 3;5,89 7,624 11,W 6,833'
Direct Expenses
Advertising/Postage/Printing 8,222 11,054 10,365 250 6,235
Annual Banquet Expenses 6,485 11,163
Board Contingency Funds 10,000 1,550 320
Contract Labor-(DFCS Employee) 21,156 21,662 20,117
Depreciation 2,769 3,854 4,440 4,313 2,574
Donation - MM Ministries (30904 Clinic & Staff) 50,000 62,079 21,536 25,000
Start up & Management 126,064 150,000 156,000 162,000 160,860
Meetings/Office Supplies 808 4,151 4,568 4,582 1,296
Other (Legal, Accounting, D&O) 8,394 5,929 5,189 5,114 3,180
Telephone 689 1,986 1,777 1,749 1,942
Travel(Employee Expenses 2,194 1,093
Total Direct Expenses 149,140 238,067 273,609 232,368 221 ,523
TOTAL EXPENSES 804,188 1,331,479 1,583,605 2,053,983 1,576,415
Other Income 594 76 41 46 14
NET TO RESERVES 211 ,467 83,879 (109,460) (190,315) 45,942