2011-08-24T18:26:32-05:00 2010-12-31 LARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 980041446 990 2010-01-01 237100868 COUNTRY DOCTOR COMMUNITY CLINIC COUN 2062991937 2101 EAST YESLER WAY NO 210 SEATTLE WA 981225900 LINDA MCVEIGH 2062991937 2011-07-13 1 PAUL M BAILEY 4252506100 2011-07-13 2010 2016-02-24 21:20:13Z LINDA MCVEIGH 500 19TH AVENUE EAST SEATTLE WA 98112 13702447 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 15 162 16 0 0 4928394 5556179 5288616 5616085 143487 60346 165142 136860 10525639 11369470 0 0 0 0 7647229 7969816 0 0 137543 2968411 3475088 10615640 11444904 -90001 -75434 7508424 7442954 3008310 2998470 4500114 4444484 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 7562636 5288616 IN 2010 COUNTRY DOCTOR COMMUNITY CLINIC PROVIDED 49,961 MEDICAL VISITS. 92% OF THE PATIENTS SEEN IN 2010 HAD INCOME LESS THAN 200% OF THE FEDERAL POVERTY LEVEL (FPL). ALL UNINSURED PATIENTS (60% OF THE TOTAL PATIENTS SEEN) EARNING LESS THAN 200% OF FPL WERE SEEN ON A SLIDING SCALE DISCOUNT. THE CARE PROVIDED UNDER THIS POLICY TOTALED $2,050,725 IN 2010. 236628 DENTAL CARE IS PROVIDED TO COUNTRY DOCTOR COMMUNITY CLINIC (CDCC) PATIENTS THROUGH A CONTRACTUAL ARRANGEMENT WITH A COMMUNITY DENTAL PROVIDER. IN 2010, 4,039 DENTAL VISITS WERE PROVIDED TO LOW INCOME, UNINSURED PATIENTS. THERE IS NO REVENUE GENERATED BY CDCC THROUGH THIS CONTRACT. 803013 THE OTHER HEALTH SERVICES PROGRAM PROVIDED 16,625 ANCILLARY HEALTH VISITS (EG NUTRITION, MENTAL HEALTH, WIC) TO LOW INCOME PATIENTS. 8602277 1 0 0 0 0 0 0 0 0 1 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 0 1 0 0 0 0 0 0 0 0 0 1 1 0 1 162 1 0 0 0 0 0 1 1 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 ADRIENE OWENS 1.00 X 0 0 0 ALISON ALLGOR 1.00 X X 0 0 0 AUGUST PIPER 1.00 X 0 0 0 CINDY GRANGER 1.00 X 0 0 0 CHERYL ANDERSON 1.00 X 0 0 0 JERRY SALE 1.00 X X 0 0 0 JOAN KLEINBERG 1.00 X X 0 0 0 LY SIENG NGO 1.00 X 0 0 0 PAMELA DUNN 1.00 X 0 0 0 PATRICK FERGUSON 1.00 X 0 0 0 ROBERT LESKO 1.00 X 0 0 0 ROBERT STRAIT 1.00 X 0 0 0 SHEILA BURROUGHS 1.00 X X 0 0 0 SARA THOMPSON 1.00 X 0 0 0 WINNIE SPERRY 1.00 X 0 0 0 LINDA MCVEIGH 35.00 X 140012 0 13558 SUSANA TANTICO 40.00 X 83731 0 10603 RICHARD KOVAR MD 32.00 X 159614 0 17045 HAROLD MOORE 35.00 X 140329 0 13451 CARRIE RUBENSTEIN MD 28.00 X 108822 0 10982 MEGAN DEBELL MD 28.00 X 106032 0 10096 BESSIE CHI 40.00 X 110205 0 12143 BRADLEY ROTER MD 24.50 X 105055 0 12357 953800 0 100235 7 0 1 0 PTSO OF WASHINGTON 710 OLIVE WAY SUITE 300 SEATTLE WA 98101 INFO TECH SUPPORT 274796 1 120855 98010 4733470 603844 5556179 THIRD PARTY PAYMENTS 900099 2083221 2083221 PATIENT FEES 621400 1952649 1952649 MEDICARE/MEDICAID PAYM 900099 1580215 1580215 5616085 28671 28671 55997 55997 55997 55997 2329611 2297936 31675 31675 31675 34051 98010 35041 -990 -990 OTHER REVENUE 900099 81853 81853 81853 11369470 5697938 0 115353 383047 159517 223530 5931624 4622333 1229387 79904 245809 190011 51996 3802 955225 695614 250034 9577 454111 342029 105969 6113 6405 6405 81644 81644 949079 708414 240569 96 386024 287353 80842 17829 439999 230634 202339 7026 54304 32709 20816 779 454816 387124 67090 602 78759 8616 70143 PHARMACEUTICALS 438296 438296 BAD DEBT 385889 385889 MISCELLANEOUS 199873 113738 74320 11815 11444904 8602277 2705084 137543 446267 635067 404915 91346 1098490 712067 442008 498992 316619 342872 7535087 4273845 2750208 3261242 2049917 1887283 0 14085 7508424 7442954 918688 959032 1751593 1724290 338029 315148 3008310 2998470 X 4355685 4361429 61374 0 83055 83055 4500114 4444484 7508424 7442954 X -75434 19803 X X 0 1 1 X 1 1 X 3826675 3939346 4565967 4928394 5556179 22816561 3826675 3939346 4565967 4928394 5556179 22816561 22816561 136949 171525 134216 95365 84668 622723 140611 94785 74227 30685 340308 2633 3939 1882 3841 12295 23791887 0.95900 0.95670 X 83055 83055 83055 83055 83055 83055 1.00000 0 0 184000 184000 4621348 2805654 1815694 182047 171363 10684 1807067 1296828 510239 740625 740625 3261242 CAPITAL LEASE 28015 FQHC ENHANCEMENT SETTLEMENT 287133 315148 11369470 11444904 -75434 -15899 35702 19803 -55631 11424314 -15899 35702 19803 11404511 -35041 -35041 11369470 11479944 35041 35041 11444903 0 11444903 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. PART XII, LINE 4B - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSES PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT SPECIAL EVENT EXPENSES DINNER 132061 98010 34051 3000 6168 20543 1000 4330 132061 98010 34051 3000 6168 20543 1000 4330 35041 -990 X X X 0 0 0 0 0 0 0 0 0 LINDA MCVEIGH 139904 0 108 0 0 0 0 0 13558 0 153570 0 0 0 RICHARD KOVAR MD 159517 0 97 0 0 0 0 0 17045 0 176659 0 0 0 HAROLD MOORE 140221 0 108 0 0 0 0 0 13451 0 153780 0 0 0 X 12 250296 COST OR SELLING PRICE 0 0 0 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: PART I, COLUMN (B): CDCHC RECEIVES VACCINES AND PHARMACEUTICALS THAT ARE DISPENSED TO PATIENTS, DONATIONS OF VARYING AMOUNTS ARE RECEIVED AT LEAST MONTHLY THROUGHOUT THE YEAR. 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 MEETING. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -15,899. DONATED SERVICES AND USE OF FACILITIES: 35,702. TOTAL TO FORM 990, PART XI, LINE 5: 19,803. PART XII, LINE 2C PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.