2017-07-14T16:11:00-05:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2016-01-01 943079770 PENINSULA COMMUNITY HEALTH SERVICES PENI 3604782366 PO BOX 960 BREMERTON WA 98337 JENNIFER KREIDLER-MOSS CEO 3604782366 2017-07-05 1 KURT BENNION CPA P01469618 4252506100 67.137.57.251 2017-07-05 10:31:09 PD P DCFA9B43EC93A59851BBAB58DFEBDB3C8F781168 3A69748B60C5562FF1572AE4C29EA0C331661B82 2016 2021-01-29 14:40:06Z JENNIFER KREIDLER-MOSS PO BOX 960 BREMERTON WA 98337 23298229 0 X WWW.PCHSWEB.ORG X 1989 WA PROVIDE ACCESSIBLE, AFFORDABLE, COMPASSIONATE, QUALITY HEALTH CARE SERVICES FOR OUR COMMUNITIES. 12 12 256 22 0 0 2872155 2923608 15734905 19132216 -2095 201404 64971 29794 18669936 22287022 0 0 0 0 12588304 14792090 0 0 0 5233033 5945291 17821337 20737381 848599 1549641 24523293 28966684 7204640 10098390 17318653 18868294 X PENINSULA COMMUNITY HEALTH SERVICES (PCHS) IS A COMMUNITY-BASED NONPROFIT ORGANIZATION THAT OFFERS QUALITY, AFFORDABLE CARE FOR CHILDREN AND ADULTS IN THE KITSAP AND OLYMPIC PENINSULA AREAS. 1 0 12229517 0 13008107 MEDICAL: DURING 2016, PCHS PROVIDED 62,609 MEDICAL ENCOUNTERS TO 18,545 PATIENTS AND 4,812 BEHAVIORAL HEALTH ENCOUNTERS TO 1,425 PATIENTS AT FIVE CLINICAL SITES LOCATED IN BREMERTON (THREE SITES), PORT ORCHARD, AND POULSBO. FULLY LICENSED CLASS A PHARMACIES ARE LOCATED AT FOUR OF THE HEALTH CENTERS AND WERE FULLY AVAILABLE TO DISBURSE LOW-COST MEDICATIONS TO ALL OF ITS QUALIFIED PATIENTS. SERVICES INCLUDE PREVENTATIVE SERVICES, IMMUNIZATIONS, SCREENINGS, HEALTH EDUCATION, AND COMMUNITY OUTREACH. PCHS OFFERS ALL SERVICES ON A SLIDING FEE SCHEDULE. 3498727 0 6124109 DENTAL: IN 2016, PCHS PROVIDED 19,250 DENTAL VISITS TO 5,702 CHILDREN AND ADULTS FOR PREVENTATIVE AND RESTORATIVE CARE. DENTAL SERVICES ARE PROVIDED AT THREE CLINICAL SITES IN BREMERTON (TWO SITES) AND PORT ORCHARD. SERVICES INCLUDE PREVENTATIVE CARE, ORAL EXAMS, ORAL HYGIENE, X-RAYS, EMERGENCY CARE AND DENTAL EDUCATION. REFERRAL SERVICES ARE OFFERED FOR MORE SPECIALIZED CARE. A SLIDING FEE SCALE IS AVAILABLE TO PATIENTS WHO QUALIFY. 15728244 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 35 0 256 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X JOEL EMERY 3604756710 PO BOX 960 BREMERTON WA 98337 CHRISTOPHER COOK PRESIDENT 3.00 X X 0 0 0 EVELYN HETRICK VICE PRESIDENT 2.00 X X 0 0 0 SHARON TUCKER VICE PRESIDENT (THROUGH NOV 2016) 2.00 X X 0 0 0 YOLANDA FONG SECRETARY 2.00 X X 0 0 0 PAUL HATHAWAY TREASURER 2.00 X X 0 0 0 MONICA BERNHARD DIRECTOR 1.00 X 0 0 0 MARY ANN BEST-RABONZA DIRECTOR 1.00 X 0 0 0 BERYL COCHRAN DIRECTOR 1.00 X 0 0 0 SHARON CROMLEY DIRECTOR 1.00 X 0 0 0 DAVID FARR DIRECTOR 1.00 X 0 0 0 RENEE KIMBALL-ROUSE DIRECTOR 1.00 X 0 0 0 AL PINKHAM DIRECTOR 1.00 X 0 0 0 JEANELL RASMUSSEN DIRECTOR 1.00 X 0 0 0 RUTHANN RAULSOME DIRECTOR (THROUGH FEB 2016) 1.00 X 0 0 0 JENNIFER KREIDLER-MOSS CEO 40.00 X 216275 0 7800 BENJAMIN POTTER CFO 40.00 X 105634 0 5850 JOEL EMERY CFO 40.00 X 37130 0 1950 AARON FORSTER CIO 40.00 X 138667 0 7800 REGINA BONNEVIE ROGERS MD MEDICAL DIRECTOR 40.00 X 292605 0 7800 MICHAEL INSANI MD DENTAL DIRECTOR 40.00 X 199206 0 7800 MANDEEP DHAWAN PHYSICIAN 40.00 X 236029 0 7800 DONNAVILLE ORTIZ PHYSICIAN 40.00 X 232719 0 7800 CLEMENT LE THANH PHYSICIAN 40.00 X 206936 0 7800 JEFFREY TAN PHYSICIAN 40.00 X 200673 0 7800 FAIRYAL KASSAM PHYSICIAN 40.00 X 193083 0 7800 2058957 0 78000 26 0 1 0 ALDRICH & ASSOCIATES 810 240TH ST SE BOTHELL WA 98021 CONSTRUCTION 179221 CROSS CULTURAL COMMUNICATIONS PO BOX 2166 SUMNER WA 98390 TRANSLATION 151056 ORIENTAL GLOW CLEANING SERVICE 3950 LOCKER ROAD SE PORT ORCHARD WA 98366 JANITORIAL 132804 3 900 2580039 342669 178 2923608 PATIENT SERVICE REVENUE 621400 19132216 19132216 19132216 64387 64387 1148224 1011207 137017 137017 137017 OTHER INCOME 621400 29794 29794 29794 22287022 19132216 0 231198 1028517 686671 341846 11008064 8711547 2296517 1663633 1229228 434405 1091876 802294 289582 13020 4830 8190 42815 15884 26931 37733 13999 23734 562503 208686 353817 12700 9017 3683 1216226 1155404 60822 638563 397200 241363 1013352 800343 213009 58879 7967 50912 285742 209582 76160 55596 55596 655045 523639 131406 49774 40071 9703 EQUIP MAINT & REPAIR 506092 314800 191292 MISCELLANEOUS 460569 264526 196043 COMMUNICATIONS 243764 184042 59722 BAD DEBT 92918 92918 20737381 15728244 5009137 0 13302003 14074421 42823 93729 1146294 2833351 169318 162711 128544 143360 15603493 6513514 7231443 9089979 2502868 2569133 24523293 28966684 4942434 7967173 2156176 2051090 106030 80127 7204640 10098390 X 17111063 18636561 207590 231733 17318653 18868294 24523293 28966684 1549641 0 X 0 1 X 1 1 1 X 1560330 1746432 2052118 2872155 2923608 11154643 12529110 12481131 16548665 15734905 19132216 76426027 14089440 14227563 18600783 18607060 22055824 87580670 0 0 0 87580670 95696 73660 83236 74842 64387 391821 95696 73660 83236 74842 64387 391821 6089 116729 26184 64971 29794 243767 14191225 14417952 18710203 18746873 22150005 88216258 0.99280 0.99160 0.00440 0.00540 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1929927 1929927 6740956 3150645 3590311 2761306 765716 1995590 3619703 2597153 1022550 551601 551601 9089979 X 21556673 122012 122012 21434661 852361 852361 22287022 20737381 0 20737381 0 20737381 PART X, LINE 2: THE CLINIC HAS RECEIVED A DETERMINATION LETTER FROM THE IRS THAT STATES IT IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS SHOWN IN THE FINANCIAL STATEMENTS. MANAGEMENT EVALUATED THE ORGANIZATION'S TAX POSITIONS AND CONCLUDED THAT THE ORGANIZATION HAD TAKEN NO SIGNIFICANT UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION (ASC). PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 122,012. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT GAIN 197,728. UNRESTRICTED CONTRIBUTIONS 18,630. TEMPORARILY RESTRICTED CONTRIBUTIONS 146,155. POOL SAVINGS REVENUE 489,848. X X X X X 0 0 0 0 0 0 0 0 0 JENNIFER KREIDLER-MOSS CEO 216275 0 0 0 0 0 0 0 7800 0 224075 0 0 0 REGINA BONNEVIE ROGERS MD MEDICAL DIRECTOR 292605 0 0 0 0 0 0 0 7800 0 300405 0 0 0 MICHAEL INSANI MD DENTAL DIRECTOR 199206 0 0 0 0 0 0 0 7800 0 207006 0 0 0 MANDEEP DHAWAN PHYSICIAN 236029 0 0 0 0 0 0 0 7800 0 243829 0 0 0 DONNAVILLE ORTIZ PHYSICIAN 232719 0 0 0 0 0 0 0 7800 0 240519 0 0 0 CLEMENT LE THANH PHYSICIAN 206936 0 0 0 0 0 0 0 7800 0 214736 0 0 0 JEFFREY TAN PHYSICIAN 200673 0 0 0 0 0 0 0 7800 0 208473 0 0 0 FAIRYAL KASSAM PHYSICIAN 193083 0 0 0 0 0 0 0 7800 0 200883 0 0 0 A WA HEALTH CARE FACILITIES AUTHORITY 911108929 2005-12-18 3000000 CONSTRUCTION FINANCING 0 0 1 A 918463 3000000 51942 2948058 2005 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WA HEALTH CARE FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 07/19/2013 FORM 990, PART III, LINE 2 DURING 2016, PCHS ADDED A NEW SITE IN BREMERTON THAT PROVIDES MEDICAL AND DENTAL SERVICES. FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION'S EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD AND THE CHAIRS OF STANDING COMMITTEES. THE EXECUTIVE COMMITTEE (A) ACTS ONLY AS NECESSARY BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS WITH ALL THE POWERS OF THE BOARD AND REPORTS AND PRESENTS FOR RATIFICATION ANY SUCH ACTION TO THE BOARD AT ITS NEXT MEETING, (B) COORDINATES THE ACTIVITIES OF THE COMMITTEES OF THE BOARD, AND (C) EVALUATES ANNUALLY THE PERFORMANCE OF THE CEO. HOWEVER, THE EXECUTIVE COMMITTEE DOES NOT HAVE AUTHORITY TO BIND THE BOARD OR THE ORGANIZATION ON ANY MATTERS INVOLVING THE PURCHASE OR SALE OF ANY REAL PROPERTY OR THE SALE OR PURCHASE OF EQUIPMENT, FURNITURE OR FIXTURES IN EXCESS OF 1% OF THE ORGANIZATION'S ANNUAL BUDGET. THE EXECUTIVE COMMITTEE HAS THE AUTHORITY TO AUTHORIZE SUBMITTAL OF GRANT APPLICATIONS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BEFORE SIGNATURE BY BOTH THE CFO AND CEO, AND WAS PRESENTED TO THE FINANCE COMMITTEE. THE BOARD TREASURER MADE A REPORT TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 12C PENINSULA COMMUNITY HEALTH SERVICES HAS A WRITTEN CONFLICT OF INTEREST POLICY THAT ALL BOARD DIRECTORS ARE REQUIRED TO SIGN ON AN ANNUAL BASIS. UPON SIGNING THE POLICY, EACH BOARD MEMBER AGREES TO DISCLOSE AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST. THE BOARD OF DIRECTORS, AT ANY TIME A POTENTIAL CONFLICT ARISES, MAY REQUIRE AN INDIVIDUAL TO REFRAIN FROM DISCUSSION OF THE MATTER, REFRAIN FROM VOTING ON THE MATTER, OR BE EXCUSED FROM ATTENDING THE PORTION OF THE MEETING ABOUT THE MATTER OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 PENINSULA COMMUNITY HEALTH SERVICES ATTEMPTS TO COMPENSATE ALL EMPLOYEES FAIRLY, EQUITABLY AND COMPETITIVELY. A SALARY SURVEY THAT INCLUDES A SALARY ANALYSIS OF LIKE JOB DESCRIPTIONS IN THE GEOGRAPHICAL AREA IS COMPLETED BY THE HUMAN RESOURCE DEPARTMENT. THE BOARD OF DIRECTORS APPROVES THE WAGE SCALE ANNUALLY. FOR THE POSITION OF THE CEO THE SALARY DATA IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. BASED ON THE INFORMATION PROVIDED, THE EXECUTIVE COMMITTEE DETERMINES THE COMPENSATION FOR THE CEO FOR THE ENSUING YEAR WHICH THE FULL BOARD APPROVES. THIS PROCESS LAST OCCURRED IN 2016. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS, POLICIES, FINANCIAL STATEMENTS AND FORMS 990 ARE PROVIDED UPON REQUEST.