2018-11-09T17:02:45-06:00 2017-12-31 990 2017-01-01 010409788 COMMUNITY CLINICAL SERVICESINC COMM 2077778546 CAMPUS AVE PO BOX 7291 LEWISTON ME 042407291 JOAN CHURCHILL EXECUTIVE DIRECTOR/CFO 2077778546 2018-11-09 155.212.6.161 2018-11-09 18:02:38 ES P A744FCA080835C7073C58A40247746B207170AF7 AEC35488C4CD91AC8DD9FF49E81978A397244AF0 2017 2019-02-21 02:37:17Z JOAN CHURCHILL 57 BIRCH ST SUITE 201 LEWISTON ME 042407291 12920787 0 X WWW.COMMUNITYCLINICALSERVICES.COM X 1984 ME PRIMARY AND SPECIALTY HEALTHCARE TO ALL RESIDENTS. 13 8 145 2 0 0 2241901 1230641 13558506 11683695 11345 6451 0 0 15811752 12920787 0 0 0 0 12372589 6900989 0 0 0 3306446 5785920 15679035 12686909 132717 233878 2830166 3626201 1634344 2593255 1195822 1032946 X COMMUNITY CLINICAL SERVICES, INC. IS A NOT-FOR-PROFIT, FEDERALLY QUALIFIED HEALTH CENTER, WHICH PROVIDES PRIMARY AND SPECIALTY HEALTHCARE SERVICES TO RESIDENTS IN THE SURROUNDING COMMUNITY REGARDLESS OF THE ABILITY TO PAY. 0 0 4264013 3799822 FAMILY PRACTICE: MEDICAL CARE FOR INFANTS, CHILDREN, AND ADULTS. 2017 VISITS - 22,023 3175754 2557234 BEHAVIORAL MEDICINE: PSYCHIATRIC CARE FOR CHILDREN AND ADULTS. 2017 VISITS - 18,850 1292744 1883689 OUTPATIENT COUNSELING: COUNSELING SERVICES FOR CHILDREN AND ADULTS. 2017 VISITS - 16,814 3297798 3442950 OTHER PROGRAM SERVICES INCLUDE DENTAL SERVICES, CARE MANAGEMENT, 340B PROGRAM REVENUE. 3297798 3442950 12030309 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 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 4 0 1 145 1 0 0 0 0 0 0 0 0 X 13 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 ME X X MICHAEL HENDRIX 2077778546 96 CAMPUS AVENUE PO BOX 7291 LEWISTON ME 042407291 ABDIFATAH AHMED DIRECTOR 3.00 X 0 0 0 BRADELY EDWARDS DIRECTOR 2.00 X 0 0 0 CAROLE MOREAU SECRETARY 2.00 X X 0 0 0 CAROLYN KASABIAN TREASURER 2.00 40.00 X X 0 249753 17230 ELIZABETH KEENE DIRECTOR 2.00 40.00 X 0 128924 7093 ELMUATZ ABDELRAHIM DIRECTOR 2.00 X 0 0 0 FOWSIA MUSSE TERMED 22017 DIRECTOR 2.00 12.00 X 4534 0 75 HASSAN OLHAYE VICE CHAIR FROM 4/17 2.00 X X 0 0 0 LAURA PETERSON DIRECTOR 2.00 X 0 0 0 MEGAN HUDSON DIRECTOR 2.00 X 0 0 0 MELISSA DUNN CHAIR 2.00 X X 0 0 0 PAIGE HAGERSTROM DIRECTOR 2.00 40.00 X 0 123245 6497 RENE DUMONT DIRECTOR 2.00 40.00 X 0 224618 17544 JOAN CHURCHILL EX OFFICIO CFO/CEO 40.00 X 92830 0 6416 SYED FAHD PHYSICIAN 40.00 X 315817 0 16438 JENISHA NANDHLAL PHYSICIAN 40.00 X 277011 0 6155 SHULAMITH BONHAM PHYSICIAN 40.00 X 210211 0 2655 CAROLYN MCNAMARA PHYSICIAN 40.00 X 125550 0 14773 SHILO MATHIEU PHYSICIAN 40.00 X 131796 0 694 1157749 726540 95570 11 0 1 0 ST MARY'S REGIONAL MEDICAL CENTER PO BOX 7291 CAMPUS AVE LEWISTON ME 042430291 PURCHASED SERVICES 1048308 BARTON ASSOCIATES INC PO BOX 417844 BOSTON MA 022417844 PEDIATRIC LOCUM 343607 1 991902 38788 199951 1230641 NET PATIENT SERVICES REVENUE 621110 10286072 10286072 OTHER PROGRAM SERVICES REVENUE 621110 826627 826627 MEDICAL DIRECTOR REVENUE 621110 570996 570996 11683695 6451 6451 12920787 11683695 0 6451 5828914 5666754 162160 27104 26678 426 644854 414641 230213 400117 393715 6402 1025 1025 25300 25300 305417 301197 4220 57637 56286 1351 64359 64359 93680 41268 52412 OUTSIDE LABOR 3086518 3082055 4463 0 PURCHASED SERVICES 1083124 1012948 70176 0 BAD DEBT 758543 758543 SUPPLIES 113024 88226 24798 0 197293 187998 9295 12686909 12030309 656600 0 631544 1946006 1239692 1223220 10511 29988 21252 784465 580508 230712 203957 698230 221255 2830166 3626201 1588938 549655 7133 45406 2036467 1634344 2593255 X 1044413 851186 151409 181760 1195822 1032946 2830166 3626201 X 233878 1399 -398153 X X 0 1 X 1 0 X 2324833 2894589 2155660 2241901 1230641 10847624 10366097 9881443 12837168 13558506 11683695 58326909 12690930 12776032 14992828 15800407 12914336 69174533 0 0 0 69174533 1082 4968 8914 11345 6451 32760 1082 4968 8914 11345 6451 32760 12692012 12781000 15001742 15811752 12920787 69207293 0.99950 0.99960 0.00050 0.00040 X 0 0 0 0 0 0 0 0 1 117 117 0 PART II-B, LINE 1: COMMUNITY CLINICAL SERVICES IS A MEMBER OF THE MAINE PRIMARY CARE ASSOCIATION AND A PORTION OF THE 2017 DUES PAID IN THE AMOUNT OF $117.00 IS USED FOR LOBBYING. 151409 37341 6990 181760 26828 126205 1624 151409 52215 19735 45122 26828 56576 40092 44452 52215 1601 55000 25 56576 1.00000 0 0 62244 17438 44806 722221 563070 159151 203957 DUE TO RESTRICTED FUNDS 181760 BOARD DESIGNATED FUNDS 39495 221255 DUE TO THIRD PARTY PAYORS 47630 DUE TO AFFILIATES 1988837 2036467 X 12922186 1399 1399 12920787 0 12920787 12686909 0 12686909 0 12686909 PART X, LINE 2: CCS IS CONSIDERED A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. TAX-EXEMPT ORGANIZATIONS COULD BE REQUIRED TO RECORD AN OBLIGATION FOR INCOME TAXES AS THE RESULT OF A TAX POSITION THEY HAVE HISTORICALLY TAKEN ON VARIOUS TAX EXPOSURE ITEMS INCLUDING UNRELATED BUSINESS INCOME OR TAX STATUS. UNDER GUIDANCE ISSUED BY THE FINANCIAL ACCOUNTING STANDARDS BOARD, ASSETS AND LIABILITIES ARE ESTABLISHED FOR UNCERTAIN TAX POSITIONS TAKEN OR POSITIONS EXPECTED TO BE TAKEN IN INCOME TAX RETURNS WHEN SUCH POSITIONS ARE JUDGED TO NOT MEET THE "MORE-LIKELY-THAN-NOT" THRESHOLD, BASED UPON THE TECHNICAL MERITS OF THE POSITION. ESTIMATED INTEREST AND PENALTIES, IF APPLICABLE, RELATED TO UNCERTAIN TAX POSITIONS ARE INCLUDED AS A COMPONENT OF INCOME TAX EXPENSE. CCS HAS EVALUATED THE POSITIONS TAKEN ON ITS FILED TAX RETURNS. CCS HAS CONCLUDED NO UNCERTAIN INCOME TAX POSITIONS EXIST AT DECEMBER 31, 2017. X X 0 0 0 0 0 0 0 1 0 CAROLYN KASABIAN TREASURER 0 249753 0 0 0 0 0 9687 0 7543 0 266983 0 0 RENE DUMONT DIRECTOR 0 224618 0 0 0 0 0 2178 0 15366 0 242162 0 0 SYED FAHD PHYSICIAN 175517 0 115300 0 25000 0 2694 0 13744 0 332255 0 0 0 JENISHA NANDHLAL PHYSICIAN 213011 0 64000 0 0 0 0 0 6155 0 283166 0 0 0 SHULAMITH BONHAM PHYSICIAN 152711 0 20000 0 37500 0 1718 0 938 0 212867 0 0 0 PART I, LINE 7 IN CONJUNCTION WITH COVENANT HEALTH THE ORGANIZATION MAINTAINS AN INCENTIVE COMPENSATION PLAN FOR EXECUTIVES THAT IS ADMINISTERED BY COVENANT HEALTH'S COMPENSATION COMMITTEE. THE PLAN PROVIDES EXECUTIVES WITH THE OPPORTUNITY TO EARN REASONABLE INCENTIVE COMPENSATION BASED ON THE PERFORMANCE OF THE INDIVIDUAL EXECUTIVE, AS MEASURED AGAINST GOALS THAT ARE SET AT THE BEGINNING OF THE YEAR. FORM 990, PART VI, SECTION A, LINE 6 ST. MARY'S HEALTH SYSTEM (SMHS) IS THE SOLE CORPORATE MEMBER WITH LIMITED RESERVE POWER. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION HAS MEMBERS THAT CAN ELECT OTHER MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL OF THE MEMBERS IS REQUIRED FOR THE DISOLUTION OR MERGER OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 WAS PROVIDED TO THE BOARD MEMBERS FOR REVIEW AND APPROVED AT THE SEPTEMBER 24 2018 MEETING. FORM 990, PART VI, SECTION B, LINE 12C THIS PROCESS IS THE RESPONSIBILITY OF ORGANIZATIONAL INTEGRITY OFFICER. A FORM IS USUALLY SUBMITTED TO ALL BOARD MEMBERS, BOARD COMMITTEE MEMBERS, AND CERTAIN EMPLOYEES IN KEY POSITIONS ANNUALLY TO BE COMPLETED. REMINDERS ARE USUALLY SENT TO MAKE CERTAIN ALL CONFLICT OF INTEREST FORMS ARE RETURNED. FORM 990, PART VI, SECTION B, LINE 15 AN EXTERNAL COMPENSATION FIRM DOES A COMPENSATION SURVEY FOR THE EXECUTIVE DIRECTOR POSITION AND THE COMPENSATION PACKAGE IS REVIEWED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION PROVIDES FORM 1023 AND FORM 990 TO THE PUBLIC WHEN REQUESTED. THE ORGANIZATION DOES NOT CURRENTLY PROVIDE ACCESS TO GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS. FORM 990, PART XI, LINE 9: CHANGE IN PERM RESTRICTED 30,351. NET ASSETS RELEASED FOR PROPERTY, PLANT & EQUIPMENT 6,990. AFFILIATED TRANSFERS -435,494. FORM 990, PART XII, LINE 2C THE AUDIT PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. ST MARY'S HEALTH SYSTEMS POBOX 7291 CAMPUS AVE LEWISTON ME 042437291 222504349 PARENT COMPANY ME 501(C)3 11A COVENANT HEALTH INC 0 ST MARY'S REGIONAL MEDICAL CENTER POBOX 7291 CAMPUS AVE LEWISTON ME 042430291 010211551 HOSPITAL ME 501(C)3 3 ST MARY'S HEALTH SYSTEM 0 ST MARY'S RESIDENCES POBOX 7291 CAMPUS AVE LEWISTON ME 042437291 222504356 LOW-INCOME HOUSING ME 501(C)3 9 ST MARY'S HEALTH SYSTEM 0 COVENANT HEALTH INC 100 AMES POND DRIVE TEWKSBURY MA 01876 222484505 HEALTHCARE MANAGEMENT AND RESOURCE ADMINISTRATION MA 501(C)3 9 0 CAMPUS HOLDING PO BOX 7291 LEWISTON ME 04240 010406049 HOLDING COMPANY ME N/A C 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 1