2019-11-15T17:55:31-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2018-01-01 237100868 COUNTRY DOCTOR COMMUNITY CLINIC COUN 2062991937 2101 EAST YESLER WAY NO 210 SEATTLE WA 98122 RALEIGH WATTS EXECUTIVE DIRECTOR 2062991937 2019-11-14 1 KURT BENNION CPA P01469618 4252506100 2019-11-14 67.137.57.251 2019-11-14 12:17:03 PS P AA627A63F630E2EFD1435F04ECCF881DFF3D020E 437A48F7A65F248D0909731AA99F0A79285329FF 2018 2020-03-31 21:24:44Z RALEIGH WATTS 2101 EAST YESLER WAY NO 210 SEATTLE WA 98122 25843967 0 X WWW.COUNTRYDOCTOR.ORG X 1971 WA TO IMPROVE THE HEALTH OF OUR COMMUNITY BY PROVIDING HEALTH CARE REGARDLESS OF ABILITY TO PAY. 16 16 240 16 0 9700 6491795 6490239 17941405 18824931 8676 11347 471890 453061 24913766 25779578 54291 58356 0 0 13391123 13703109 0 0 139679 9984023 10452165 23429437 24213630 1484329 1565948 13809129 20778385 4112829 9528283 9696300 11250102 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 19697745 57591 18824931 IN 2018, COUNTRY DOCTOR COMMUNITY CLINIC PROVIDED 56,968 MEDICAL VISITS. 64% OF THE PATIENTS SEEN IN 2018 HAD INCOME LESS THAN 200% OF THE FEDERAL POVERTY LEVEL (FPL). 22% WERE UNINSURED PATIENTS. 1487563 765 0 THE OTHER HEALTH SERVICES PROGRAMS PROVIDED 5,839 ANCILLARY HEALTH VISITS (EG NUTRITION, WIC, ELIGIBILITY) TO LOW-INCOME PATIENTS. 21185308 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 51 0 240 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 16 16 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X SUSANA TANTICO 2062991937 2101 EAST YESLER WAY SUITE 210 SEATTLE WA 98122 MORGAN DUTTON CHAIR & DIRECTOR 1.00 X X 0 0 0 COLT DEWOLF TREASURER & CHAIR 1.00 X X 0 0 0 RIK WYMAN VICE CHAIR 1.00 X X 0 0 0 JOAN KLEINBERG SECRETARY 1.00 X X 0 0 0 NICK UREN DIRECTOR & TREASURER 1.00 X X 0 0 0 CHERYL ANDERSON DIRECTOR 1.00 X 0 0 0 RAYMOND ANGEL DIRECTOR 1.00 X 0 0 0 MARLON BROWN DIRECTOR 1.00 X 0 0 0 MARY BYRD DIRECTOR 1.00 X 0 0 0 ALEX CURRY DIRECTOR 1.00 X 0 0 0 ELVIRA DAVISON DIRECTOR 1.00 X 0 0 0 MARY DOWNS DIRECTOR 1.00 X 0 0 0 LORI FREE DIRECTOR 1.00 X 0 0 0 ROB ROCHE DIRECTOR 1.00 X 0 0 0 GRANT SCULL DIRECTOR 1.00 X 0 0 0 LY SIENG NGO DIRECTOR 1.00 X 0 0 0 RALEIGH WATTS EXECUTIVE DIRECTOR 35.00 X 174952 0 9320 SUSANA TANTICO DIRECTOR OF FINANCE 40.00 X 124536 0 20655 CHRIS SALAZAR DEPUTY DIRECTOR 40.00 X 132987 0 9320 MATT LOGALBO MEDICAL DIRECTOR 40.00 X 200522 0 3820 RICHARD KOVAR PHYSICIAN, RESIDENCY PROGRAM DIR. 28.00 X 190418 0 18159 KRISTIN ANDERSON PHYSICIAN, RESIDENCY PROGRAM DIR. 32.00 X 183438 0 9320 BESSIE CHI PHARMACIST 40.00 X 147682 0 8684 SONJA OLSON PHYSICIAN 26.00 X 134961 0 18159 1289496 0 97437 27 0 1 0 MARPAC CONSTRUCTION 1225 S WELLER STREET SUITE 500 SEATTLE WA 98144 CONSTRUCTION 7616554 PTSO OF WASHINGTON 3101 4TH AVENUE SUITE 320 SEATTLE WA 98101 I.T. SUPPORT 431786 CHILDRENS HOSPITAL P O BOX 24728 SEATTLE WA 98124 FACILITY MANAGEMENT 247480 ENVIROMENTAL WORKS 402 15TH AVENUE E SEATTLE WA 98112 ARCHITECT 160488 OCHIN 1881 SW NAITO PARKWAY PORTLAND OR 97201 I.T. SERVICES 140453 7 166232 6200850 123157 251020 6490239 PATIENT SERVICES 621400 9434031 9434031 PHARMACY 621400 9390900 9390900 18824931 11347 11347 50655 0 50655 50655 50655 44022 166232 64389 -20367 -20367 RISK POOL 900099 330005 330005 OTHER REVENUE 900099 92768 92768 422773 25779578 18824931 0 464408 57591 57591 765 765 471770 471770 10613521 9359962 1168348 85211 496316 442681 49931 3704 1295817 1190832 95020 9965 825685 736456 83066 6163 6907 4655 2198 54 60356 40674 19211 471 2147123 1978064 159929 9130 245914 176208 59978 9728 426996 298164 128849 -17 24203 14801 7768 1634 64593 39501 20732 4360 11195 1991 9002 202 270852 251088 19764 89810 89810 UBI TAXES 2037 2037 MEDICAL SUPPLIES 6038570 6038570 BAD DEBT 467996 467996 MISCELLANEOUS 317330 35818 277454 4058 278283 49491 223776 5016 24213630 21185308 2888643 139679 3052856 1584854 13763 13147 1680019 1844593 3774125 3574138 498181 434059 20119501 7216451 4365321 12903050 424864 424544 13809129 20778385 2164509 3393795 1948320 6134488 4112829 9528283 X 9613245 11167047 83055 83055 9696300 11250102 13809129 20778385 1565948 -12146 0 X 0 1 X 1 1 1 X 5043959 4710371 6421155 6491795 6490239 29157519 5043959 4710371 6421155 6491795 6490239 29157519 29157519 108335 90336 107142 76720 62002 444535 1012271 61194 133356 474041 466795 2147657 31749711 82363341 0.91840 0.91680 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER REVENUE RISK POOL REVENUE DEBT FORGIVENESS SPECIAL FUNDRAISING EVENTS CHARITABLE GAMING EVENTS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 83055 83055 83055 83055 83055 83055 83055 83055 83055 83055 0.00000 1.00000 0.00000 0 0 184000 184000 6780574 4687209 2093365 182047 182047 0 2852725 2347195 505530 10120155 10120155 12903050 X 24735097 64389 64389 24670708 1108870 1108870 25779578 24278019 64389 64389 24213630 0 24213630 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 X, LINE 2: CDCHC'S ACTIVITIES ARE GENERALLY EXEMPT FROM FEDERAL INCOMES TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; HOWEVER, UNRELATED BUSINESS ACTIVITIES WOULD BE SUBJECT TO INCOME TAX. SINCE CDCHC IS EXEMPT FROM FEDERAL INCOME TAX LIABILITY, NO PROVISION IS MADE FOR CURRENT OR DEFERRED INCOME TAX EXPENSE. FOR THE YEARS ENDED DECEMBER 31, 2018 AND 2017, MANAGEMENT EVALUATED CDCHC'S TAX POSITIONS AND CONCLUDED THAT CDCHC HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS. ALL TAX-EXEMPT ENTITIES ARE SUBJECT TO REVIEW AND AUDIT BY FEDERAL, STATE, AND OTHER APPLICABLE STATE STATUTES, USUALLY FOR THREE YEARS SUBSEQUENT TO THE DATE THE RETURN WAS FILED. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 64,389. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL INCOME 50,655. CAPITAL CAMPAIGN CONTRIBUTIONS 58,215. CAPITAL GRANTS 1,000,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 64,389. FUNDRAISING DINNER 210254 166232 44022 9764 37748 16877 210254 166232 44022 9764 37748 16877 64389 -20367 1 YWCA SEATTLE 1118 5TH AVENUE SEATTLE WA 98101 910482890 501(C)(3) 57591 FEDERAL RYAN WHITE PROGRAM DISTRIBUTION TO SUB-RECIPIENT 1 0 PART I, LINE 2: COUNTRY DOCTOR MONITORS THE USE OF FUNDS DISTRIBUTED TO SUB-RECIPIENTS THROUGH FEDERAL GRANT PROGRAMS IN ACCORDANCE WITH THE REQUIREMENTS FOR THOSE PROGRAMS. X X X X X 0 0 0 0 0 0 0 0 0 RALEIGH WATTS EXECUTIVE DIRECTOR 174952 0 0 0 0 0 0 0 9320 0 184272 0 0 0 MATT LOGALBO MEDICAL DIRECTOR 200522 0 0 0 0 0 0 0 3820 0 204342 0 0 0 RICHARD KOVAR PHYSICIAN, RESIDENCY PROGRAM DIR. 190418 0 0 0 0 0 0 0 18159 0 208577 0 0 0 KRISTIN ANDERSON PHYSICIAN, RESIDENCY PROGRAM DIR. 183438 0 0 0 0 0 0 0 9320 0 192758 0 0 0 BESSIE CHI PHARMACIST 147682 0 0 0 0 0 0 0 8684 0 156366 0 0 0 SONJA OLSON PHYSICIAN 134961 0 0 0 0 0 0 0 18159 0 153120 0 0 0 GABRIELLE WILLIAMS DAUGHTER OF SUSANA TANTICO, DIRECTOR OF FINANCE 11490 EMPLOYEE COMPENSATION 0 X 12 251020 COST/SELLING PRICE 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE BOARD CHAIR AND AT LEAST THREE OTHER BOARD MEMBERS. THE EXECUTIVE COMMITTEE HAS THE AUTHORITY AS EXPRESSLY DELEGATED TO IT BY RESOLUTION OF THE BOARD IN THE GOVERNANCE OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B THE EXECUTIVE DIRECTOR AND DIRECTOR OF FINANCE BOTH REVIEWED A DRAFT OF THE RETURN BEFORE IT WAS PRESENTED TO THE FINANCE COMMITTEE FOR FURTHER REVIEW. AFTER REVIEW BY THE FINANCE COMMITTEE AND DISTRIBUTION TO THE FULL BOARD THE FORM 990 WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C COMPLIANCE AND NON-COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY 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 HIM OR HERSELF 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 AS WELL AS A MILLIMAN SURVEY THAT ASSESSES MARKET COMPENSATION. THE LAST REVIEW PROCESS OF THE EXECUTIVE DIRECTOR'S COMPENSATION WAS DONE IN 2017. THE DIRECTOR OF FINANCE'S COMPENSATION IS REVIEWED BY THE EXECUTIVE DIRECTOR BASED ON A MILLIMAN SURVEY THAT ASSESSES MARKET COMPENSATION. THE BOARD THEN REVIEWS IT ALONG WITH ALL OTHER EMPLOYEES AS A GROUP. THE REVIEW OF THE DIRECTOR OF FINANCE'S COMPENSATION WAS DONE IN 2017. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC.