2017-05-14T12:25:50-05:00 2016-06-30 911194016 CLARK NUBER PS 10900 NE 4TH STREET SUITE 1700 BELLEVUE WA 98004 990 2015-07-01 911255170 COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY COMM 4257893700 8609 EVERGREEN WAY EVERETT WA 98208 VICTORIA M RINGNESS CHIEF FINANCIAL OFFICER 4257893700 2017-05-10 1 SARA ELIZABETH J HYRE P00235495 4254544919 2017-05-10 2015 2021-01-29 14:40:06Z ROBERT C FARRELL 8609 EVERGREEN WAY EVERETT WA 98208 49085165 0 X WWW.CHCSNO.ORG X 1986 WA TO PROVIDE OUR DIVERSE COMMUNITY WITH ACCESS TO HIGH QUALITY, AFFORDABLE PRIMARY HEALTH CARE. 11 11 467 108 0 0 5057685 6171222 29550009 34547709 505130 355695 1159779 990337 36272603 42064963 0 0 0 0 24004503 28315113 0 0 214428 10705999 12186624 34710502 40501737 1562101 1563226 71529045 73048491 8601195 8502864 62927850 64545627 X COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY ("CHC") PROVIDES MEDICAL AND DENTAL CARE TO LOW-INCOME/HOMELESS INDIVIDUALS WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES ON A SLIDING FEE BASIS. ALL PATIENTS ARE REQUIRED TO PAY A MINIMUM FEE, AND NO PATIENT IS DENIED SERVICES DUE TO AN INABILITY TO PAY. SINCE MANAGEMENT DOES NOT EXPECT PAYMENT FOR THE DISCOUNTED PORTION OF CARE, THE DISCOUNTED SERVICES ARE EXCLUDED FROM REVENUE. DURING THE YEAR ENDED JUNE 30, 2016, CHC PROVIDED $2,448,445 OF CHARITY CARE SERVICES UNDER THIS POLICY. 0 0 18537080 19943521 MEDICAL CARE - TO PROVIDE MEDICAL SERVICES IN PEDIATRICS, ACUTE GENERAL CARE AND OBSTETRICAL CARE TO LOW-INCOME/ HOMELESS PEOPLE AT FIVE DIFFERENT CLINIC LOCATIONS. COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY ALSO OFFERS PRENATAL CARE, BEHAVIORAL HEALTH SERVICES, IMMUNIZATIONS, AND CHRONIC DISEASE MANAGEMENT TO INDIVIDUALS AND FAMILIES FROM A WIDE VARIETY OF ETHNIC AND CULTURAL BACKGROUNDS. COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY EMPLOYS A MULTI-LINGUAL STAFF, PROVIDES EXTENDED HOURS AND SAME-DAY APPOINTMENTS FOR COMMUNITY RESIDENTS. FEES ARE PAID ON A SLIDING FEE SCALE AND BY THIRD-PARTY INSURANCE, MEDICARE AND MEDICAID. THERE WAS A TOTAL OF 104,741 PATIENT ENCOUNTERS FOR THIS FISCAL YEAR. CHARITY CARE SERVICES FOR THE YEAR TOTALED $1,378,969. IN ADDITION, CHC PROVIDED PRIMARY CARE OUTREACH SERVICES FOR HOMELESS INDIVIDUALS AND FAMILIES AT THREE TRANSITIONAL HOUSING AGENCIES IN SNOHOMISH COUNTY. 12663702 14604188 DENTAL CARE - TO PROVIDE DENTAL SERVICES TO LOW-INCOME/HOMELESS PEOPLE ON A SLIDING FEE BASIS AND BY THIRD-PARTY INSURANCE AND MEDICAID AT FIVE DIFFERENT CLINICS. THERE WAS A TOTAL OF 79,094 PATIENT ENCOUNTERS FOR THIS FISCAL YEAR. CHARITY CARE SERVICES FOR THE YEAR TOTALED $1,069,476. 2185265 941547 PHARMACY SERVICES - TO PROVIDE PHARMACY SERVICES TO LOW-INCOME PEOPLE ON A SLIDING FEE BASIS AND BY THIRD-PARTY INSURANCE AND MEDICAID AT FIVE DIFFERENT CLINICS. 116,724 TOTAL PRESCRIPTIONS WERE FILLED FOR THIS FISCAL YEAR. 33386047 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 37 0 1 467 1 0 0 0 0 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 1 0 WA X VICTORIA M RINGNESS 4257893703 8609 EVERGREEN WAY EVERETT WA 98208 BICH-NGA NGUYEN BOARD MEMBER 2.00 X 0 0 0 COURTNEY MILLER CHAIR 2.00 X X 0 0 0 REBECCA PRATT VICE CHAIR 2.00 X X 0 0 0 LENORA ROSE BOARD MEMBER 2.00 X 0 0 0 SAMUEL HOLTZMAN BOARD MEMBER 2.00 X 0 0 0 LINDA INGLIN TREASURER 2.00 X X 0 0 0 TRACY CUAJAO BOARD MEMBER 2.00 X 0 0 0 BRYTFIRTH BRYT HASAPHONGSE SECRETARY 2.00 X X 0 0 0 TAMIKO LEWIS BOARD MEMBER 2.00 X 0 0 0 ANNE VAN LEYNSEELE BOARD MEMBER 2.00 X 0 0 0 DOLORES BLUEFORD BOARD MEMBER 2.00 X 0 0 0 ROBERT C FARRELL CPA CHIEF EXECUTIVE OFFICER 45.00 X 171818 0 23555 VICTORIA RINGNESS CHIEF FINANCIAL OFFICER 45.00 X 131106 0 14507 LISA M MILLER CHIEF OPERATING OFFICER 45.00 X 125710 0 13852 DION C KAPETANOV CHIEF ADMIN OFFICER 45.00 X 135469 0 14177 THOMAS M TOCHER CHIEF CLINICAL OFFICER 45.00 X 266481 0 23994 AMY RODRIGUEZ PHYSICIAN 45.00 X 188098 0 17649 ALEX H KOSLOFF PHYSICIAN 45.00 X 205295 0 29534 AHMED ELKADY DENTIST 45.00 X 194828 0 6640 RUTH ANN PARISH DIRECTOR, CLINICAL 45.00 X 217304 0 19655 SCOTT R MCAFEE DIRECTOR, CLINICAL 45.00 X 202010 0 7773 TOVE R SKAFTUN FORMER OFFICER & DIRECTOR OF NURSING 45.00 X 129544 0 14686 1967663 0 186022 59 1 1 0 JR ABBOTT CONSTRUCTION INC 3408 1ST AVE S SUITE 101 SEATTLE WA 981248448 CONSTRUCTION 1762477 TECHHEADS 7060 SW BEVELAND RD PORTLAND OR 97223 IT SUPPORT SERVICES 386148 COMPHEALTH INC PO BOX 972670 DALLAS TX 753976270 TEMP. HEALTHCARE STAFFING 315475 STAFF CARE PO BOX 281923 ATLANTA GA 303841923 TEMP. HEALTHCARE STAFFING 247124 LANGUAGE LINE SERVICES PO BOX 202564 DALLAS TX 753202572 TRANSLATION SERVICES 173211 10 75954 5576892 518376 1063437 6171222 MEDICARE/MEDICAID 621400 29162668 29162668 PATIENT FEES 621110 3334514 3334514 CAPITATED REVENUE 621110 1941131 1941131 QUALITY CARE PAYMENTS 621110 109396 109396 34547709 442210 442210 3776528 3863043 -86515 -86515 -86515 4098706 3157159 941547 941547 PATIENT RECORDS 561000 25948 25948 REFUNDS & REBATES 561000 8978 8978 VARIOUS STIPENDS 561000 6759 6759 7105 7105 48790 42064963 35489256 0 404485 1053506 1053506 22523624 19553505 2886556 83563 477750 397017 76731 4002 2495472 2092910 393920 8642 1764761 1457027 301552 6182 29892 29892 64412 64412 68583 68583 1454258 1041043 391268 21947 58193 58193 409800 327727 74544 7529 153182 112257 38884 2041 911138 776811 132236 2091 38671 21880 15171 1620 278358 172368 105292 698 255234 16504 238730 2861446 2502999 355920 2527 139529 106578 32829 122 CLINICAL SUPPLIES 2405398 2404339 1059 BAD DEBT EXPENSE 1040957 1040957 EQUIPMENT RENTAL/ MAINT 766041 592806 173065 170 MINOR EQUIPMENT 554213 517748 33575 2890 697319 251571 434596 11152 40501737 33386047 6901262 214428 2971868 4131636 2235741 2142773 361595 465200 4269185 5100577 439027 527112 332088 307394 57267548 14788635 43528941 42478913 17390600 17894886 71529045 73048491 2681138 2954533 63960 47032 5853915 5501299 2182 0 8601195 8502864 X 62849467 64471753 78383 73874 62927850 64545627 71529045 73048491 1563226 54551 0 X 0 1 X 1 1 1 X 3472657 4021131 8403906 5057685 6171222 27126601 22237878 23039999 28662623 31983068 38646415 144569983 68894 30849 39485 37849 25948 203025 25779429 27091979 37106014 37078602 44843585 171899609 0 0 0 171899609 598703 566492 509108 482688 442210 2599201 598703 566492 509108 482688 442210 2599201 26087 34384 80956 -1506 22842 162763 26404219 27692855 37696078 37559784 45308637 174661573 0.98420 0.97970 0.01490 0.01880 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: INSURANCE SETTLEMENT - 2013 AMOUNT: $ 54,482. 2014 AMOUNT: $ -20,046. 2015 AMOUNT: $ 0. REFUNDS AND REBATES - 2011 AMOUNT: $ 15,875. 2012 AMOUNT: $ 24,916. 2013 AMOUNT: $ 18,930. 2014 AMOUNT: $ 4,218. 2015 AMOUNT: $ 8,978. VARIOUS INCENTIVES - 2014 AMOUNT: $ 9,876. 2015 AMOUNT: $ 6,759. MISCELLANEOUS - 2011 AMOUNT: $ 10,212. 2012 AMOUNT: $ 9,468. 2013 AMOUNT: $ 7,544. 2014 AMOUNT: $ 4,446. 2015 AMOUNT: $ 7,105. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6537339 6537339 42142129 9416778 32725351 330653 314274 16379 7804465 5049004 2755461 452962 8579 444383 42478913 45208090 54551 54551 45153539 68583 -3157159 -3088576 42064963 43590313 3157159 3157159 40433154 68583 68583 40501737 PART XI, LINE 4B - OTHER ADJUSTMENTS: COST OF GOODS SOLD INCLUDED IN EXPENSE ON FINANCIAL STATEMENTS -3,157,159. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD INCLUDED IN EXPENSE ON FINANCIAL STATEMENTS 3,157,159. X X X X 0 0 0 0 0 0 0 0 0 ROBERT C FARRELL CPA CHIEF EXECUTIVE OFFICER 161818 0 10000 0 0 0 8935 0 14620 0 195373 0 0 0 THOMAS M TOCHER CHIEF CLINICAL OFFICER 265123 0 1358 0 0 0 13412 0 10582 0 290475 0 0 0 AMY RODRIGUEZ PHYSICIAN 151357 0 36741 0 0 0 9416 0 8233 0 205747 0 0 0 ALEX H KOSLOFF PHYSICIAN 201305 0 3990 0 0 0 10755 0 18779 0 234829 0 0 0 AHMED ELKADY DENTIST 129713 0 65115 0 0 0 0 0 6640 0 201468 0 0 0 RUTH ANN PARISH DIRECTOR, CLINICAL 210270 0 7034 0 0 0 8428 0 11227 0 236959 0 0 0 SCOTT R MCAFEE DIRECTOR, CLINICAL 198092 0 3918 0 0 0 6284 0 1489 0 209783 0 0 0 TOVE R SKAFTUN FORMER OFFICER & DIRECTOR OF NURSING 125400 0 4144 0 0 0 6467 0 8219 0 144230 0 0 0 A WASHINGTON HEALTH CARE FACILITIES AUTHORITY 911108929 2013-09-20 6000000 BUILDING CONSTRUCTION 0 0 0 A 498701 6000000 110061 5889939 2014 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 X 22768 1063437 COST OR SELLING PRICE 0 0 1 0 PART I, COLUMN (B): THE NUMBER IN COLUMN B IS BASED ON THE NUMBER OF ITEMS CONTRIBUTED. FORM 990, PART I, LINE 6 VOLUNTEERS STAFFED SEVERAL HEALTH FAIRS AND PATIENT EVENTS. THESE VOLUNTEERS WERE PREDOMINANTLY EMPLOYEES WHO VOLUNTEERED THEIR TIME. MEMBERS OF THE BOARD OF DIRECTORS ARE ALSO VOLUNTEERS. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS REVIEWS AND APPROVES CHC'S FORM 990 PRIOR TO ITS FILING WITH THE IRS. THE APPROVAL PROCESS IS AS FOLLOWS: THE BOARD OF DIRECTORS RECEIVE A COPY OF FORM 990 AND MAKE A MOTION AND VOTE TO APPROVE THE FORM 990. UPON THE BOARD OF DIRECTORS' APPROVAL, THE FORM 990 IS ELECTRONICALLY FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CHC OF SNOHOMISH COUNTY EMPLOYEE HANDBOOK CONTAINS THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. EACH EMPLOYEE AND BOARD MEMBER IS REQUIRED TO SIGN OFF AS HAVING READ THE HANDBOOK AND HAVING UNDERSTOOD THIS CONFLICT OF INTEREST POLICY. PER THIS POLICY, ALL EMPLOYEES AND BOARD MEMBERS ARE REQUIRED TO AVOID AND REPORT SITUATIONS THAT COULD CREATE OR RESULT IN A REAL OR PERCEIVED CONFLICT OF INTEREST BY DISCLOSING THE RELATIONSHIP, ACTIVITY OR ASSOCIATION TO THEIR MANAGER OR HUMAN RESOURCES. BOARD MEMBERS WHO BELIEVE THAT A CONFLICT OF INTEREST EXISTS NEED TO INFORM THE CHAIR OF THE BOARD, WHO WOULD WORK WITH THE CEO TO INQUIRE INTO THE FACTS AND DETERMINE WHETHER A CONLICT OF INTEREST EXISTS. WHERE A CONFLICT OF INTEREST OCCURS, THE INDIVIDUAL IS RECUSED FROM ANY DECISION MAKING PROCESS OR MEETINGS RELATED TO THAT SITUATION. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS ANNUALLY REVIEWS THE CHIEF EXECUTIVE OFFICER COMPENSATION AND PERFORMS A PERFORMANCE EVALUATION TO SET COMPENSATION. THE HUMAN RESOURCES MANAGER MAY ASSIST AS NECESSARY. ALL OTHER OFFICERS' COMPENSATION IS SET BY HUMAN RESOURCES. THE SALARY RANGE IS BASED ON COMMUNITY COMPENSATION DATA AND YEARS OF PROFESSIONAL EXPERIENCE AND QUALIFICATIONS. ANNUAL REVIEWS OF COMPENSATION WERE LAST PERFORMED IN MARCH 2016. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST ONLY.