0000899243-16-027927.txt : 20160823 0000899243-16-027927.hdr.sgml : 20160823 20160823170012 ACCESSION NUMBER: 0000899243-16-027927 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20151215 FILED AS OF DATE: 20160823 DATE AS OF CHANGE: 20160823 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: USMD Holdings, Inc. CENTRAL INDEX KEY: 0001507881 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-GENERAL MEDICAL & SURGICAL HOSPITALS, NEC [8062] IRS NUMBER: 272866866 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 6333 NORTH STATE HIGHWAY 161 STREET 2: SUITE 200 CITY: IRVING STATE: TX ZIP: 75038 BUSINESS PHONE: 214-493-4000 MAIL ADDRESS: STREET 1: 6333 NORTH STATE HIGHWAY 161 STREET 2: SUITE 200 CITY: IRVING STATE: TX ZIP: 75038 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Collini M. Patrick CENTRAL INDEX KEY: 0001556961 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35639 FILM NUMBER: 161847709 MAIL ADDRESS: STREET 1: 1410 LONG AND WINDING ROAD CITY: MANSFIELD STATE: TX ZIP: 76063 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2015-12-15 0 0001507881 USMD Holdings, Inc. USMD 0001556961 Collini M. Patrick 1410 LONG AND WINDING ROAD MANSFIELD TX 76063 1 0 0 0 Common Stock ($.01 par value) 2015-12-15 4 A 0 1987 7.65 A 22844 D Common Stock ($.01 par value) 130929 I Indirectly held through UANT Ventures, L.P. Common Stock ($.01 par value) 13248 I Indirectly held through M. Patrick Collini, MD, P.A. Option to purchaser 24.84 2012-08-31 2017-08-31 Common Stock ($0.01 par) 1800 1800 I Indirectly held through UANT Ventures, L.P. 7.25% Convertible Subordinated Note due 2020 10.61 2016-04-29 Common Stock ($0.01 par) 18850 18850 D Represents stock compensation issued pursuant to the 2010 USMD Holdings, Inc. Equity Compensation Plan and granted to Dr. Collini in lieu of compensation of $15,201 for his services as a physician employed by an affiliate of the issuer. The noteholder has the right at any time after April 29, 2016 but prior to the payment in full of the note by the issuer, to convert all or any portion of the unpaid principal balance of the note into shares of the issuer's common stock. This conversion right expires on November 1, 2020, the maturity date of the note, or upon the earlier payment in full of the unpaid principal balance of the note. /s/ M. Patrick Collini 2016-08-23