2020-06-29T08:06:36-05:00 2019-06-30 221478099 COHNREZNICK LLP 350 CHURCH STREET 12TH FLOOR HARTFORD CT 06103 990 2018-07-01 223160873 STAYWELL HEALTH CARE INC STAY 2037568021 80 PHOENIX AVENUE NO 201 WATERBURY CT 06702 DONALD J THOMPSON JR CHIEF EXECUTIVE OFFICER 2037568021 2020-03-26 1 PAUL BALLASY P00852868 9592007000 2020-03-11 209.59.242.35 2020-03-26 13:59:56 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B0AD6F4DA9753D811CB14F2348605CBBEABD616D 2018 2020-09-23 17:36:50Z DONALD J THOMPSON JR 80 PHOENIX AVENUE NO 201 WATERBURY CT 06702 25304593 0 X WWW.STAYWELLHEALTH.ORG X 1992 CT PROVIDE PRIMARY HEALTH CARE, DENTAL, MENTAL HEALTH, AND SOCIAL SERVICES, TO THE UNDERSERVED POPULATION OF THE GREATER WATERBURY COMMUNITY. 11 11 260 0 0 0 7585180 7803540 15150782 17291153 293774 34692 -92387 -24186 22937349 25105199 0 0 0 0 16805202 18014642 0 0 0 6129092 7030293 22934294 25044935 3055 60264 11853181 11437753 2757509 2284561 9095672 9153192 PROVIDE PRIMARY HEALTH CARE, DENTAL, MENTAL HEALTH, AND SOCIAL SERVICES, TO THE UNDERSERVED POPULATION OF THE GREATER WATERBURY COMMUNITY. 0 0 22586608 17416662 MEDICAL CLINIC, HEALTHY START, AND DENTAL CLINIC WHICH PROVIDE MEDICAL, PRENATAL, AND CHILDCARE FOR INNER CITY RESIDENTS AND UNINSURED RESIDENTS AND RESTORATIVE DENTAL CARE FOR INNER CITY CHILDREN. THE TOTAL NUMBER OF VISITS DURING FISCAL YEAR 2019 WAS 100,460. 22586608 1 1 0 0 0 1 0 0 0 0 1 0 0 0 1 1 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 1 123 0 1 260 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CT X LULE TRACEY 2037568021 80 PHOENIX AVENUE SUITE 201 WATERBURY CT 06702 CAROLYN A HIGHSMITH TREASURER 1.00 X X 0 0 0 DANA M EVORA BOARD MEMBER 0.50 X 0 0 0 HERBERT L TERRY III BOARD MEMBER 0.50 X 0 0 0 LINDA RICCIARDI BOARD MEMBER 0.50 X 0 0 0 MARK BRIGGS CHAIRPERSON 1.00 X X 0 0 0 QUY TRAN OUTGOING BOARD MEMBER 0.50 X 0 0 0 REV DR MAYNER TYSON BOARD MEMBER 0.50 X 0 0 0 RICHARD LEE BOARD MEMBER 0.50 X 0 0 0 SANDRA J SOREL-LEDUC VICE CHAIR 1.00 X X 0 0 0 THOMAS JOHNSON SECRETARY 1.00 X X 0 0 0 WALTER R MACHNICZ BOARD MEMBER 0.50 X 0 0 0 WANDA DUNBAR BOARD MEMBER 0.50 X 0 0 0 DONALD J THOMPSON JR CEO 40.00 X 240633 0 45885 LULE TRACEY CFO 40.00 X 208015 0 17936 AMIT PATEL DENTAL DIRECTOR 40.00 X 211006 0 45568 TESS LOMBARD MD CHIEF MEDICAL OFFICER 40.00 X 261828 0 48197 ELIE HELOU INTERNIST MD 40.00 X 181893 0 23804 NICOLE MAKSYMIW INTERNIST MD 40.00 X 185778 0 13542 RADHIKA AGRAWAL PEDIATRICIAN MD 40.00 X 167424 0 38160 STEPHEN SPEAR INTERNIST MD 40.00 X 199843 0 25316 VICKY B TOLA INTERNIST MD 40.00 X 182897 0 10968 1839317 0 269376 25 0 1 0 WELLMORE INC 141 E MAIN STREET WATERBURY CT 06702 BH SERVICES 557970 BUSHKA LUMBAR 305 FAIRFIELD AVE WATERBURY CT 06708 CONSTRUCTION SERVICES 319579 GREENWAY HEALTH PO BOX 203658 DALLAS TX 75320 SOFTWARE PURCHASER, SOFTWARE SUPPORT & M 286543 JANI-KING OF HARTFORD INC PO BOX 415346 BOSTON MA 02241 JANITORIAL SERVICES 116121 3 12000 7791540 944532 7803540 MEDICAID 621400 11215894 11215894 PHARMACY 340B 446110 3489509 3489509 SELF-PAY PATIENTS 621400 1212626 1212626 MEDICARE 621400 962191 962191 THIRD-PARTY PAYORS 621400 410933 410933 17291153 21069 21069 42609 190458 -147849 -147849 -147849 13623 0 13623 13623 13623 7090 12000 8936 -1846 -1846 INCENTIVE PAYMENTS 900099 68596 68596 MEDICAL RECORDS COPYING FEES 900099 56913 56913 125509 25105199 17416662 0 -115003 1345217 1210695 134522 12783302 11504972 1278330 624056 561650 62406 2183881 1965493 218388 1078186 970367 107819 95568 95568 38731 38731 1931799 1753305 178494 25889 23497 2392 31083 28211 2872 56689 56689 410131 372236 37895 75932 68916 7016 109156 99070 10086 7455 6766 689 329178 298763 30415 102518 93046 9472 CLINIC SUPPLIES 1546890 1403961 142929 VACCINES 944532 944532 PROVISION FOR UNCOLLECT 861656 861656 EQUIPMENT RENTAL AND MA 194689 176700 17989 268397 242772 25625 25044935 22586608 2458327 0 1890462 1984319 2477571 2178081 708331 785620 1481305 1248312 300974 353753 8606654 3990120 4716023 4616534 26878 24980 83333 83333 168304 162821 11853181 11437753 1191182 1343632 131927 146689 1434400 794240 2757509 2284561 X 6665293 9153192 2430379 0 9095672 9153192 11853181 11437753 60264 -2744 0 X X 0 1 X 1 1 1 X 5068232 5787182 7413613 7585180 7803540 33657747 5068232 5787182 7413613 7585180 7803540 33657747 33657747 166084 132727 125490 45794 63678 533773 260398 127115 106621 63314 132599 690047 34881567 72208623 0.96490 0.95460 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MEANINGFUL USE INCENTIVE - 2014 AMOUNT: $ 233,750. 2015 AMOUNT: $ 102,000. 2016 AMOUNT: $ 63,750. 2018 AMOUNT: $ 68,596. MISCELLANEOUS - 2014 AMOUNT: $ 26,648. 2015 AMOUNT: $ 25,115. 2016 AMOUNT: $ 42,871. 2017 AMOUNT: $ 59,114. 2018 AMOUNT: $ 56,913. FUNDRAISING - 2017 AMOUNT: $ 4,200. 2018 AMOUNT: $ 7,090. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1898 0 0 384297 384297 6743579 2830152 3913427 1478778 1159968 318810 4616534 ACCRUED PROFIT SHARING 669395 SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN 124845 794240 X 24249735 -2744 -1052114 -1054858 25304593 -199394 -199394 25105199 24192215 199394 199394 23992821 1052114 1052114 25044935 PART X, LINE 2: THE CENTER WAS INCORPORATED AS A NOT-FOR-PROFIT ENTITY AND IS EXEMPT FROM FEDERAL INCOME TAX UNDER THE PROVISIONS OF THE INTERNAL REVENUE CODE SECTION 501(C)(3), EXCEPT FOR TAXES ON UNRELATED BUSINESS INCOME. THE CENTER HAS NO UNRECOGNIZED TAX BENEFITS AT JUNE 30, 2019 AND 2018. THE CENTER'S FEDERAL AND STATE INFORMATION RETURNS PRIOR TO FISCAL YEAR 2016 ARE CLOSED AND MANAGEMENT CONTINUALLY EVALUATES EXPIRING STATUTES OF LIMITATIONS, AUDITS, PROPOSED SETTLEMENTS, CHANGES IN TAX LAW AND NEW AUTHORITATIVE RULINGS. IF THE CENTER HAS UNRELATED BUSINESS INCOME TAXES, IT WILL RECOGNIZE INTEREST AND PENALTIES ASSOCIATED WITH UNCERTAIN TAX POSITIONS AS PART OF THE INCOME TAX PROVISION AND INCLUDE ACCRUED INTEREST AND PENALTIES WITH THE RELATED TAX LIABILITY IN THE STATEMENTS OF FINANCIAL POSITION. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -1,052,114. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES -8,936. RENT EXPENSES -190,458. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES 190,458. FUNDRAISING EXPENSES 8,936. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 1,052,114. ANNUAL FETE 19090 12000 7090 1495 300 4485 600 2056 19090 12000 7090 1495 300 4485 600 2056 8936 -1846 X X X 0 1 0 0 0 0 0 1 0 DONALD J THOMPSON JR CEO 234633 0 6000 0 0 0 14467 0 31418 0 286518 0 0 0 LULE TRACEY CFO 202015 0 6000 0 0 0 16500 0 1436 0 225951 0 0 0 AMIT PATEL DENTAL DIRECTOR 205006 0 6000 0 0 0 13050 0 32518 0 256574 0 0 0 TESS LOMBARD MD CHIEF MEDICAL OFFICER 245828 0 16000 0 0 0 15288 0 32909 0 310025 0 0 0 ELIE HELOU INTERNIST MD 178453 0 3440 0 0 0 12125 0 11679 0 205697 0 0 0 NICOLE MAKSYMIW INTERNIST MD 183218 0 2560 0 0 0 10934 0 2608 0 199320 0 0 0 RADHIKA AGRAWAL PEDIATRICIAN MD 165886 0 1538 0 0 0 10242 0 27918 0 205584 0 0 0 STEPHEN SPEAR INTERNIST MD 199843 0 0 0 0 0 12283 0 13033 0 225159 0 0 0 VICKY B TOLA INTERNIST MD 182897 0 0 0 0 0 10968 0 0 0 193865 0 0 0 PART I, LINE 4B DONALD J. THOMPSON, JR. RECEIVED A DISTRIBUTION OF $14,467 FOR CALENDAR YEAR 2018 FROM HIS 457F PLAN WHICH WAS INCLUDED IN HIS W2. PART I, LINE 7 THE CENTER PROVIDED AN ANNUAL BOARD APPROVED PROFIT SHARING BONUS. X 1 944532 COST 0 0 0 PART I, COLUMN (B): THE AMOUNT IN COLUMN B REPRESENTS THE NUMBER OF CONTRIBUTORS. FORM 990, PART VI, SECTION B, LINE 11B THE 990 WILL BE REVIEWED AND ACCEPTED BY THE BOARD BEFORE STAYWELL SUBMITS. FORM 990, PART VI, SECTION B, LINE 12C DONALD THOMPSON, CEO, MONITORS CONFLICT OF INTEREST POLICY BY REVIEWING AND ADDRESSING ANY POTENTIAL CONFLICTS AND FOLLOWING UP EACH YEAR FOR ANY CHANGES. BOARD MEMBERS ARE REQUIRED TO SIGN THE POLICY ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A INFORMATION FROM NATIONAL AND STATEWIDE SURVEYS ARE USED AS CRITERIA TO DETERMINE THE SALARY OF THE CEO. THIS INFORMATION IS GIVEN TO THE PERSONNEL COMMITTEE FOR REVIEW. THE PERSONNEL COMMITTEE NEGOTIATES AND APPROVES THE SALARY OF THE CEO. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C: THERE HAVE BEEN NO CHANGES MADE TO THE ORGANIZATION'S OVERSIGHT OR SELECTION PROCESS DURING THE TAX YEAR.