2013-11-11T15:53:25-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2012-01-01 237100868 COUNTRY DOCTOR COMMUNITY CLINIC COUN 2062991937 2101 EAST YESLER WAY NO 210 SEATTLE WA 981225900 LINDA MCVEIGH 2062991937 2013-11-11 1 PAUL MBAILEY P00292653 4252506100 2013-11-08 2012 2016-03-07 17:11:31Z LINDA MCVEIGH 500 19TH AVENUE EAST SEATTLE WA 98112 11236450 0 X WWW.COUNTRYDOCTOR.ORG X 1971 WA THE MISSION OF COUNTRY DOCTOR COMMUNITY CLINIC IS TO IMPROVE THE HEALTH OF OUR COMMUNITY BY PROVIDING HIGH QUALITY, CARING, CULTURALLY APPROPRIATE PRIMARY HEALTH CARE THAT ADDRESSESS THE NEEDS OF PEOPLE REGARDLESS OF THEIR ABILITY TO PAY. 15 15 182 16 0 0 4792780 4856236 5393367 5991341 14210 37684 646771 301808 10847128 11187069 0 0 0 0 8070734 8291100 0 0 127786 3098796 3362624 11169530 11653724 -322402 -466655 7032258 7923410 2898251 4265446 4134007 3657964 THE MISSION OF COUNTRY DOCTOR COMMUNITY CLINIC IS TO IMPROVE THE HEALTH OF OUR COMMUNITY BY PROVIDING HIGH QUALITY, CARING, CULTURALLY APPROPRIATE PRIMARY HEALTH CARE THAT ADDRESSESS THE NEEDS OF PEOPLE REGARDLESS OF THEIR ABILITY TO PAY. 0 0 8987514 6181648 IN 2012 COUNTRY DOCTOR COMMUNITY CLINIC PROVIDED 48,687 MEDICAL VISITS. 88% OF THE PATIENTS SEEN IN 2012 HAD INCOME LESS THAN 200% OF THE FEDERAL POVERTY (FPL). ALL UNINSURED PATIENTS (53% OF THE TOTAL PATIENTS SEEN) EARNING LESS THAN 200% OF FPL WERE SEEN ON A SLIDING SCALE DISCOUNT. 60520 30000 DENTAL CARE IS PROVIDED TO COUNTRY DOCTOR COMMUNITY CLINC (CDCC) PATIENTS THROUGH A CONTRACTUAL ARRANGEMENT WITH A COMMUNITY DENTAL PROVIDER. IN 2012, 171 DENTAL VISITS WERE PROVIDED TO LOW INCOME, UNINSURED PATIENTS. 1140640 THE OTHER HEALTH SERVICES PROGRAM PROVIDED 14,876 ANCILLARY HEALTH VISITS (EG NUTRITION, MENTAL HEALTH, WIC, ELIGIBILITY) TO LOW INCOME PATIENTS. 10188674 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 182 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 15 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WA X SUSANA TANTICO 2062991937 2101 EAST YESLER WAY SUITE 210 SEATTLE WA 98122 AUGUST PIPER 1.00 X 0 0 0 CHERYL ANDERSON 1.00 X 0 0 0 COLT DEWOLF 1.00 X 0 0 0 JERRET SALE 1.00 X 0 0 0 JOAN KLEINBERG 1.00 X X 0 0 0 LY SIENG NGO 1.00 X X 0 0 0 PAMELA DUNN 1.00 X 0 0 0 PATRICK FERGUSON 1.00 X X 0 0 0 RIK WYMAN 1.00 X 0 0 0 SARA THOMPSON 1.00 X 0 0 0 WINNIE SPERRY 1.00 X 0 0 0 MORGAN DUTTON 1.00 X 0 0 0 MARY BYRD 1.00 X 0 0 0 CARLA KROEZE 1.00 X 0 0 0 ALLAN GUIDEN 1.00 X 0 0 0 LINDA MCVEIGH 35.00 X 148456 0 13374 RICHARD KOVAR 31.00 X 158289 0 18334 HAROLD MOORE 35.00 X 145496 0 14246 CARRIE RUBENSTEIN 28.00 X 110291 0 11137 MEGAN DEBELL 28.00 X 110290 0 10686 JEFFERY WARNER 21.00 X 111368 0 10958 784190 0 78735 9 0 1 0 PTSO OF WASHINGTON 3101 FOURTH AVE SUITE 320 SEATTLE WA 98101 INFO TECH SUPPORT 304729 1 57000 4196962 602274 262995 4856236 PATIENT FEES 621400 2609587 2609587 THIRD PARTY PAYMENTS 900099 1832909 1832909 MEDICARE/MEDICAID PAYMENTS 900099 1548845 1548845 5991341 37684 37684 58463 0 58463 58463 58463 72419 57000 49381 23038 23038 OTHER REVENUE 900099 220307 220307 220307 11187069 6211648 0 119185 338452 133631 204821 6254835 5825503 346301 83031 264098 223309 37541 3248 757256 654591 92961 9704 676459 571981 96158 8320 82158 82158 71872 71872 726481 693665 32790 26 247325 175575 53639 18111 349892 233276 113554 3062 37536 27224 9985 327 414324 390096 24146 82 89133 8174 80959 BAD DEBT 582298 582298 PHARMACEUTICALS 467670 467670 OTHER HEALTHCARE SUPPLI 148856 148817 39 MISCELLANEOUS 145079 52864 90340 1875 11653724 10188674 1337264 127786 308879 284735 91367 734297 597017 778079 923118 460170 469121 9194834 5027527 2992864 4167307 1653174 1482112 13428 0 7032258 7923410 878509 1205977 1697853 2756386 321889 303083 2898251 4265446 X 4050952 3574909 83055 83055 4134007 3657964 7032258 7923410 -466655 -9388 0 X X 0 1 X 1 1 1 X 4565967 4928394 5556179 4792780 4856236 24699556 4565967 4928394 5556179 4792780 4856236 24699556 24699556 134216 95365 84668 57372 96147 467768 94785 74227 30685 78158 -49381 228474 1882 3841 5723 25401521 0.97240 0.96080 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 83055 83055 83055 83055 83055 83055 83055 83055 83055 83055 0 0 184000 184000 6780574 3283280 3497294 182047 171633 10414 2048213 1572614 475599 4167307 CAPITAL LEASE 15950 FQHC ENHANCEMENT SETTLEMENT 287133 303083 X 11308949 -9388 81887 49381 121880 11187069 0 11187069 11784992 81887 49381 131268 11653724 0 11653724 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE ASSETS SET ASIDE AND RESTRICTED BY DONORS. THE INCOME GENERATED FROM THESE ASSETS IS USED TO FUND OPERATIONS OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: CDCHC 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. NO PROVISION FOR INCOME TAXES IS SHOWN IN THE FINANCIAL STATEMENTS BECAUSE CDCHC IS A NONPROFIT ORGANIZATION, EXEMPT FROM INCOME TAXES. MANAGEMENT EVALUATED CDCHC'S TAX POSITIONS AND CONCLUDED THAT CDCHC HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION. CDCHC IS NO LONGER SUBJECT TO U.S. FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSE PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSE PART XII, LINE 4B - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSES PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSES CDCHC 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. NO PROVISION FOR INCOME TAXES IS SHOWN IN THE FINANCIAL STATEMENTS BECAUSE CDCHC IS A NOT-FOR-PROFIT ORGANIZATION, EXEMPT FROM INCOME TAXES. MANAGEMENT EVALUATED CDCHCS TAX POSITIONS AND CONCLUDED THAT CDCHC HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION. CDCHC IS NO LONGER SUBJECT TO U.S. FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2008. FUND RAISING DINNER 129419 57000 72419 13513 1000 34868 129419 57000 72419 13513 1000 34868 49381 23038 X X X 0 0 0 0 0 0 0 0 0 LINDA MCVEIGH 148348 0 108 0 0 0 0 0 13374 0 161830 0 0 0 RICHARD KOVAR 158192 0 97 0 0 0 0 0 18334 0 176623 0 0 0 HAROLD MOORE 145388 0 108 0 0 0 0 0 14246 0 159742 0 0 0 X 12 262955 COST OR SELLING PRICE 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE EXECUTIVE DIRECTOR AND DIRECTOR OF FINANCE BOTH REVIEW A DRAFT OF THE RETURN BEFORE IT IS PRESENTED TO THE FINANCE COMMITTEE FOR FURTHER REVIEW. AFTER REVIEW BY THE FINANCE COMMITTEE AND DISTRIBUTION TO THE FULL BOARD THE FORM 990 IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C COMPLIANCE AND NON-COMPLIANCE WERE REGULARLY AND CONSISTENTLY MONITORED AND ENFORCED DURING THE MONTHLY MEETINGS. BOARD MEMBERS SIGN A CONFLICT OF INTEREST FORM ANNUALLY. ANY MEMBER WITH A STATED CONFLICT OF INTEREST IS REVIEWED BY THE EXECUTIVE COMMITTEE. THE BOARD CHAIRPERSON DETERMINES THE EXTENT OF THE CONFLICT AND WHETHER THE CONFLICTED BOARD MEMBER SHOULD NOT VOTE ON AN ISSUE OR SHOULD RECUSE THEMSELF FROM THE DISCUSSION. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE DIRECTOR'S COMPENSATION IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTORS. EVERY TWO YEARS THIS PROCESS IS ASSISTED BY AN INDEPENDENT COMPENSATION CONSULTANT. THE LAST REVIEW PROCESS OF THE EXECUTIVE DIRECTOR'S COMPENSATION WAS DONE IN AUGUST 2010. THE DIRECTOR OF FINANCE'S COMPENSATION IS DETERMINED ANNUALLY BY THE BOARD BASED ON A MILLIMAN SURVEY THAT ASSESSES MARKET COMPENSATION. THE REVIEW OF THE DIRECTOR OF FINANCE'S COMPENSATION WAS DONE IN JULY 2010. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEARS.