2014-08-15T09:01:36-05:00 2013-12-31 481032601 ALLEN GIBBS & HOULIK LC 301 N MAIN SUITE 1700 WICHITA KS 672024868 990 2013-01-01 481159633 GRACEMED HEALTH CLINIC INC GRAC 3168662001 1122 N TOPEKA WICHITA KS 67214 DAVID SANFORD CEO 3168662011 2014-08-14 1 JENNIFER A ALLEN P01338336 3162677231 2013 2015-11-30 17:44:51Z DAVID SANFORD 1122 N TOPEKA WICHITA KS 67214 12426764 0 X WWW.GRACEMED.ORG X 1979 KS TO PROVIDE PRIMARY HEALTH AND DENTAL CARE SERVICES TO KANSANS WITHOUT HEALTH INSURANCE OR ADEQUATE FINANCIAL RESOURCES TO SECURE TRADITIONAL HEALTH CARE SERVICES. 16 16 231 50 0 0 3916800 3163301 6885367 8646990 45973 -58447 84923 31562 10933063 11783406 0 0 0 0 6586637 7754946 0 0 19322 2894484 3056963 9481121 10811909 1451942 971497 6712014 7535112 1146641 899515 5565373 6635597 TO SHOW AND SHARE THE LOVE OF JESUS CHRIST BY PROVIDING COMPASSIONATE, ACCESSIBLE, HIGH-QUALITY HEALTH CARE FOR RESIDENTS OF SOUTH CENTRAL KANSAS. 0 0 8888559 8568034 PROVIDING PRIMARY HEALTH AND DENTAL CARE TO KANSANS WITHOUT HEALTH INSURANCE OR ADEQUATE FINANCIAL RESOURCES TO SECURE TRADITIONAL HEALTH CARE SERVICES 8888559 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 9 0 1 231 0 0 0 0 0 0 0 1 1 0 X 16 16 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 1 0 0 0 KS X SHAROL SULLIVAN 3168662049 1122 N TOPEKA WICHITA KS 67214 FRED ERVIN BOARD MEMBER 4.00 X 0 0 0 TOM BORREGO BOARD MEMBER 4.00 X 0 0 0 TERRY BOURLARD BOARD MEMBER 4.00 X 0 0 0 GARY BROOKS BOARD MEMBER 4.00 X 0 0 0 SALLY CHESSER BOARD MEMBER 4.00 X 0 0 0 LOU ANN EWERTT BOARD MEMBER 4.00 X 0 0 0 MICHAEL GOOD BOARD MEMBER 4.00 X 0 0 0 LAURIE LABARCA BOARD MEMBER 4.00 X 0 0 0 GAROLD MINNS BOARD MEMBER 4.00 X 0 0 0 MARC MINNIS BOARD MEMBER 4.00 X 0 0 0 GAIL FINNEY BOARD MEMBER 4.00 X 0 0 0 BARTON PRINCE BOARD MEMBER 4.00 X 0 0 0 JON ROSELL BOARD MEMBER 4.00 X 0 0 0 DENISE WREN BOARD MEMBER 4.00 X 0 0 0 ABE RODRIGUEZ BOARD MEMBER 4.00 X 0 0 0 SUSAN HOWEY BOARD MEMBER 4.00 X 0 0 0 RUSSELL JOHNSON CHIEF MEDICAL OFFICER 40.00 X 180003 0 4875 VENUS LEE CHIEF OPERATING OFFICER 40.00 X 95055 0 1660 DR ROGER NOLTE CHIEF DENTAL OFFICER 40.00 X 139029 0 4429 DAVID SANFORD CHIEF EXECUTIVE OFFICER 40.00 X 128754 0 8737 SHAROL SULLIVAN CHIEF FINANCIAL OFFICER 40.00 X 91249 0 2753 DR ANDREA BOOTHE DENTIST 40.00 X 110574 0 6533 DR TERESA JOHNSON DOCTOR 40.00 X 120265 0 8483 DR PHILLIP BROCKINGTON DENTIST 40.00 X 124320 0 4875 DR JAMIE PAGE DOCTOR 40.00 X 104179 0 8000 DR ELIZABETH WAWRZEWSKI DOCTOR 40.00 X 108533 0 3271 1201961 0 53616 16 0 1 0 USD #259 201 N WATER WICHITA KS 67202 CLINIC CONSTRUCTION 803897 HENRY SCHEIN INC DEPT CH 10241 PALATINE IL 60055 DENTAL SUPPLIES 312421 USD #260 120 E WASHINGTON DERBY KS 67037 CLINIC CONSTRUCTION 218642 PEARCE TURK DENTAL LABORATORY 5775 WAYZATA BLVD SUITE 890 MINNEAPOLIS MN 55416 DENTAL LAB 213255 MCKESSON DRUG PO BOX 409521 ATLANTA GA 30384 PHARMACY SUPPLIES 212882 9 35195 2495205 632901 3163301 MEDICAL & DENTAL SERVICES 621110 8340990 8340990 HIT CERT INCENTIVE 621110 306000 306000 8646990 32863 32863 339321 180730 336676 274685 2645 -93955 -91310 -93955 2645 48560 35195 31997 16563 16563 MISC REVENUE 900099 14999 14999 14999 11783406 8568034 0 52071 634090 517851 116239 6523364 5325404 1196036 1924 58148 52907 5142 99 539344 451164 86937 1243 120518 120518 258167 250328 7839 51440 46688 4752 121216 72516 48700 345606 325779 19827 13871 13871 328780 308900 19880 24643 2612 22031 MEDICAL SUPPLIES 1016310 1014438 1872 CONSULTING & COMPUTER E 298376 203738 94618 20 UTILITIES 175121 154553 20568 REPAIRS 120429 103155 17274 182486 105214 65988 11284 10811909 8888559 1904028 19322 354337 315808 1054753 941064 382886 473550 125000 4599 4915 41884 28784 5703683 1426517 3767574 4277166 1103890 1242330 2091 126495 6712014 7535112 979690 835083 166951 64432 1146641 899515 X 5546501 6375710 18872 259887 5565373 6635597 6712014 7535112 971497 98727 0 X X 0 1 X 1 1 1 X 2644753 2178498 2025778 3961224 3211861 14022114 3684944 3839861 5181866 6953176 8661989 28321836 6329697 6018359 7207644 10914400 11873850 42343950 0 0 0 42343950 12237 16939 31644 45973 -58447 48346 12237 16939 31644 45973 -58447 48346 6341934 6035298 7239288 10960373 11815403 42392296 0.99890 0.99680 0.00110 0.00320 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3784312 472663 3311649 1919371 953854 965517 4277166 12371076 98727 456946 31997 587670 11783406 0 11783406 11300852 456946 31997 488943 10811909 0 10811909 PART XI, LINE 2D - OTHER ADJUSTMENTS: EXPENSES REPORTED ON SCHEDULE G 31,997. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES REPORTED ON SCHEDULE G 31,997. 5K RACE 83755 35195 48560 1000 13696 1245 16056 83755 35195 48560 1000 13696 1245 16056 31997 16563 X X 1 0 0 0 0 0 0 0 0 RUSSELL JOHNSON CHIEF MEDICAL OFFICER 180003 0 0 0 0 0 0 0 4875 0 184878 0 0 0 PART I, LINE 4A RUSSELL JOHNSON RECEIVED $31,154 OF SEVERANCE PAYMENT. SALLY CHESSER BOARD MEMBER 0 GRACEMED HEALTH CLINIC, INC. HOLDS AN INVESTMENT ACCOUNT WITH SALLY CHESSER AT TD AMERITRADE. SALLY DOES NOT CHARGE A FEE FOR HER SERVICES. 0 CHAD SANFORD SON OF CEO 42979 CHAD SANFORD IS THE SON OF DAVID SANFORD, CEO OF GRACEMED. CHAD IS AN EMPLOYEE OF GRACEMED. 0 JOHN BORREGO SON OF BOARD MEMBER 27537 JOHN BORREGO IS THE SON OF TOM BORREGO, THE PRESIDENT OF THE BOARD OF DIRECTORS. JOHN BORREGO IS AN EMPLOYEE OF GRACEMED 0 SARA BAYLESS DAUGHTER OF OFFICER 52939 SARA BAYLESS IS THE DAUGHTER OF ROGER NOLTE, GRACEMED'S CHIEF DENTAL OFFICER. SARA BAYLESS IS AN EMPLOYEE OF GRACEMED. 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION HIRES AN OUTSIDE CPA TO PREPARE THE FINANCIAL STATEMENT AUDIT AND THE FORM 990 EACH YEAR. AFTER THE CPA HAS COMPLETED BOTH THE AUDIT AND FORM 990, THE CFO FOR THE ORGANIZATION AND THE CPA REVIEW THE INITIAL DRAFT OF THE RETURN TO ENSURE ITS COMPLETENESS AND ACCURACY. FOLLOWING THE REVIEW, THE FORM 990 IS COMPLETED AND THE ORGANIZATION FILES THE RETURN. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES THE GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICIES, AND AUDITED FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C THIS POLICY HAS NOT CHANGED SINCE THE PRIOR YEAR.