2012-09-28T15:50:37-05:00 2012-06-30 020400296 BRAD BORBIDGE PA 197 LOUDON ROAD STE 350 CONCORD NH 03301 990 2011-07-01 020350051 COOS COUNTY FAMILY HEALTH SERVICES INC COOS 6037522040 133 PLEASANT STREET BERLIN NH 03570 ROBERT PELCHAT 6037527719 2012-09-28 1 DIMITRIOS PANACOPOULOS CPA P01603705 6032240849 2011 2016-02-24 21:20:13Z ADELE WOODS 133 PLEASANT STREET BERLIN NH 03570 8476900 0 X WWW.COOSFAMILYHEALTH.ORG X 1980 NH COOS COUNTY FAMILY HEALTH SERVICES, INC. IS A COMMUNITY-BASED ORGANIZATION PROVIDING INNOVATIVE, PERSONALIZED, COMPREHENSIVE HEALTH CARE AND SOCIAL SERVICES OF THE HIGHEST QUALITY TO EVERYONE, REGRDLESS OF ECONOMIC STATUS. 13 13 131 20 0 0 3560033 2785222 5699859 5687797 1882 3881 0 0 9261774 8476900 0 0 0 0 6521850 6443676 0 0 369 2226632 2124783 8748482 8568459 513292 -91559 3675928 4503072 1659153 2577856 2016775 1925216 COOS COUNTY FAMILY HEALTH SERVICES, INC. IS A COMMUNITY-BASED ORGANIZATION PROVIDING INNOVATIVE, PERSONALIZED, COMPREHENSIVE HEALTH CARE AND SOCIAL SERVICES OF THE HIGHEST QUALITY TO EVERYONE, REGARDLESS OF ECONOMIC STATUS. 0 0 7462559 5687797 PROVISION OF PRIMARY CARE SERVICES TO THE COMMUNITY. 7462559 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 35 0 1 131 1 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X X ADELE WOODS 6037522040 133 PLEASANT STREET BERLIN NH 03570 ROBERT PELCHAT 0.00 X 0 0 0 JOAN MERRILL 0.00 X 0 0 0 BETTY GOSSELIN 0.00 X 0 0 0 ALINE BOUCHER 0.00 X 0 0 0 MARGE MCCLELLAN 0.00 X 0 0 0 ASA BROSNAN 0.00 X 0 0 0 LINDA SLOWIK 0.00 X 0 0 0 MICHAEL POULIN 0.00 X 0 0 0 H GUYFORD STEVER JR 0.00 X 0 0 0 KENNETH CARGILL 0.00 X 0 0 0 LINDA SJOSTROM 0.00 X 0 0 0 JEFFREY SMITH 0.00 X 0 0 0 DAVID SMITH 0.00 X 0 0 0 ADELE WOODS 40.00 X 131193 0 7751 MELISSA FRENETTE 40.00 X 88082 0 6808 PATRICIA COUTURE 40.00 X 97457 0 5926 MITCHELL SULLIVAN MD 40.00 X 169424 0 30774 BRIAN BEALS 37.50 X 178442 0 32594 KEERTHY KRISHNAMANI 33.00 X 112445 0 21523 THOMAS TEMME 33.00 X 129241 0 30715 JOSEE BOURBEAU MD 34.00 X 169165 0 31732 1075449 0 167823 8 0 1 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL RD BERLIN NH 03570 RENT/PHYSICIANS/OB 334325 1 4491 2061170 719561 2785222 HOME HEALTH CARE SRVCS 621610 5687797 5687797 5687797 3881 3881 8476900 5687797 0 3881 537415 327978 209437 4524404 4071964 452440 142531 124073 18458 838481 729898 108583 400845 348936 51909 7298 7298 29566 29566 286410 286410 13843 13843 91900 79999 11901 139349 139349 326827 284503 42324 25600 22285 3315 80029 80029 41447 36080 5367 237004 206312 30692 49470 43064 6406 BAD DEBT EXPENSE 286208 286208 PROGRAM SUPPLIES 247187 247187 PRINTING AND PUBLICATIO 71578 62309 9269 TELEPHONE 63933 55654 8279 127134 110350 16415 369 8568459 7462559 1105531 369 290233 905538 129460 247547 417670 376734 84769 62585 4237448 2000522 2100167 2236926 653629 673742 3675928 4503072 784415 716759 793834 874738 1067263 1659153 2577856 X 813154 871052 1186701 1035587 16920 18577 2016775 1925216 3675928 4503072 -91559 0 X 0 1 1 X 1 1 X 2988706 3089355 3420596 3560033 2785222 15843912 5955938 5860487 5664361 5699859 5687797 28868442 8944644 8949842 9084957 9259892 8473019 44712354 0 0 0 44712354 1992 1477 1273 1882 3881 10505 1992 1477 1273 1882 3881 10505 8946636 8951319 9086230 9261774 8476900 44722859 0.99980 0.99980 0.00020 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 17623 1657 -173 19107 15874 2003 -254 17623 12919 2917 38 15874 11446 1173 300 12919 0.97000 0.03000 0 0 153257 153257 2557494 837005 1720489 1526697 1163517 363180 2236926 DUE FROM THIRD PARTY PAYERS 41000 ASSETS LIMITED AS TO USE 632742 673742 8476900 8568459 -91559 -91559 8476900 0 8476900 0 8476900 8568459 0 8568459 0 8568459 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: INCOME EARNED IS USED FOR OPERATIONS. PART IV, LINE 11F - THE ORGANIZATION IS A PUBLIC CHARITY UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS A PUBLIC CHARITY, THE ORGANIZATION IS EXEMPT FROM STATE AND FEDERAL INCOME TAXES ON INCOME EARNED IN ACCORDANCE WITH ITS TAX EXEMPT PURPOSE. UNRELATED BUSINESS INCOME IS SUBJECT TO STATE AND FEDERAL INCOME TAX. MANAGEMENT HAS EVALUATED THE ORGANIZATION'S TAX POSITIONS AND CONCLUDED THAT THE ORGANIZATION HAS NO UNRELATED BUSINESS INCOME OR UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS. X X X X 0 0 0 0 0 0 0 1 0 MITCHELL SULLIVAN MD 146691 0 22733 0 0 0 0 0 30774 0 200198 0 0 0 BRIAN BEALS 151768 0 26674 0 0 0 0 0 32594 0 211036 0 0 0 THOMAS TEMME 119241 0 10000 0 0 0 0 0 30715 0 159956 0 0 0 JOSEE BOURBEAU MD 133291 0 35874 0 0 0 0 0 31732 0 200897 0 0 0 PART I, LINE 7 PHYSICIANS ARE PROVIDED INCENTIVE PAYMENTS BASED ON NUMBER OF PATIENTS SEEN, COMPLEXITY OF PATIENT ACUITY, TIMELY DOCUMENTATION, PATIENT SATISFICATION, AND QUALITY OF CARE PROVIDED. ADELE WOODS CEO 113751 THE ORGANIZATION IS A PARTICIPANT OF THE NORTH COUNTRY ACCOUNTABLE CARE ORGANIZATION (NCACO). THE NCACO WAS CREATED TO UNDERTAKE PROGRAMS AND ACTIVITIES OF ACO PARTICIPANTS FOR THE PURPOSE OF PARTICIPATING IN THE MEDICARE SHARED SAVINGS PROGRAM FOR SERVICES TO MEDICARE BENEFICIARIES. ADELE WOODS IS ALSO THE VICE PRESIDENT OF THE BOARD OF DIRECTORS FOR THE NCACO. THE TRANSACTION AMOUNT REPORTED REPRESENTS STARTUP MONIES AND SHARED SAVINGS PASSED THROUGH TO THE ORGANIZATION FROM THE NCACO THROUGH JUNE 30, 2012. 0 FORM 990, PART VI, SECTION B, LINE 11 THE CFO COMPARES THE FORM 990 TO THE AUDITED FINANCIAL STATEMENTS AND PRIOR YEAR 990. A COPY IS GIVEN TO THE FINANCE COMMITTEE TO REVIEW AND THEN A COPY IS GIVEN TO THE BOARD OF DIRECTORS TO REVIEW AND APPROVE. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE BOARD RE-AFFIRMS THEIR COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY WITH A WRITTEN COMPLIANCE DOCUMENT. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION PROCESS FOR THE CEO, COO AND CFO INCLUDES AN INDEPENDENT COMPENSATION CONSULTANT COMPLETING A COMPENSATION SURVEY OR STUDY. THE COMPENSATION AMOUNT IS THEN APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE POSTED TO THE ORGANIZATION'S WEBSITE AND ARE AVAILABLE UPON REQUEST.