2015-11-12T15:16:42-06:00 2015-01-31 410746749 CLIFTONLARSONALLEN LLP 370 INTERLOCKEN BLVD SUITE 500 BROOMFIELD CO 80021 990 2014-02-01 840743432 CLINICA CAMPESINA FAMILY HEALTH SERVICES CLIN 3036504460 1345 PLAZA COURT NORTH NO 1A LAFAYETTE CO 80026 SIMON G SMITH PRESIDENT & CEO 3036504460 2015-06-04 1 KURT BENNION P01469618 3034668822 2014 2016-03-07 17:11:31Z CLINICA FAMILY HEALTH SERVICES SIMON G SMITH 1345 PLAZA COURT NORTH NO 1A LAFAYETTE CO 80026 40012759 0 X WWW.CLINICA.ORG X 1977 CO PROVIDE HIGH-QUALITY, CULTURALLY APPROPRIATE CARE TO LOW-INCOME AND OTHER UNDESERVED PEOPLE. 11 11 548 15 0 0 15091658 13349799 20858986 26327131 3641 1225 218472 334604 36172757 40012759 0 0 0 0 26370843 29426793 0 0 226017 9983977 10485629 36354820 39912422 -182063 100337 30180885 30514963 3259380 3493121 26921505 27021842 X TO BE THE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE PROVIDER OF CHOICE FOR LOW-INCOME AND OTHER UNDERSERVED PEOPLE IN SOUTH BOULDER, BROOMFIELD AND WEST ADAMS COUNTIES. OUR CARE SHALL BE CULTURALLY APPROPRIATE AND PREVENTION FOCUSED. OUR VISION IS TO ASSURE THAT EVERY LOW-INCOME AND OTHER UNDERSERVED PERSON IN THESE AREAS HAVE ACCESS TO HIGH-QUALITY, PREVENTATIVE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE. 0 0 29725590 0 26327131 FOR FISCAL YEAR 2015, CLINICA PROVIDED 152,387 MEDICAL VISITS, 20,214 DENTAL VISITS, 15,514 BEHAVIORAL HEALTH VISITS, 2,158 REGISTERED DIETICIAN VISITS, AND 24,845 CASE MANAGEMENT VISITS. 29725590 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 90 0 548 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 CO X BETSY DAVID 3036504460 1345 PLAZA COURT NORTH 1A LAFAYETTE CO 80026 MANDY M RIGG CHAIR 1.00 X X 0 0 0 GLADYS JOHNSON CHAIR-ELECT 1.00 X X 0 0 0 MICHAEL MORAN TREASURER & CHAIR-ELECT 1.00 X X 0 0 0 ELIZABETH SHAFFER SECRETARY 1.00 X X 0 0 0 DAMON BROWN DIRECTOR 1.00 X 0 0 0 INEZ BUGGS DIRECTOR 1.00 X 0 0 0 BEN GOLDSTEIN DIRECTOR 1.00 X 0 0 0 W DOUGLAS JONES DIRECTOR 1.00 X 0 0 0 MARYANN KELLER DIRECTOR 1.00 X 0 0 0 MICHELLE KREZEK DIRECTOR 1.00 X 0 0 0 LOIS LACROIX DIRECTOR 1.00 X 0 0 0 CHERLYN MARRIOTT DIRECTOR 1.00 X 0 0 0 ELEANOR MONTOUR DIRECTOR 1.00 X 0 0 0 LIBBEY SMITH DIRECTOR 1.00 X 0 0 0 DONOVAN TULLOCH DIRECTOR 1.00 X 0 0 0 SIMON G SMITH PRESIDENT & CEO 40.00 X 167762 0 34293 ELIZABETH A DAVID CFO 40.00 X 9503 0 6405 SEAN C SAUNDERS CFO THROUGH 8/4/2014 40.00 X 220134 0 6602 KAREN FUNK VP OF CLINICAL SERVICES 40.00 X 211976 0 35432 JUSTIN D WHEELER VP OF CLINICAL SERVICES 40.00 X 206163 0 30613 AN T NGUYEN VP OF DENTAL SERVICES 40.00 X 154291 0 9963 PHILIP J KEPPELER PHYSICIAN 40.00 X 234905 0 26262 CHRISTOPHER J KEENAN PHYSICIAN 40.00 X 225498 0 18201 COLLEEN KEPNER PHYSICIAN 40.00 X 231754 0 11896 JESSICA KENERSON PHYSICIAN 40.00 X 219048 0 16863 EDWARD L FARRELL PHYSICIAN 40.00 X 193102 0 21740 2074136 0 218270 47 0 1 0 TECHNICAL MOMENTUM LLC 5197 S VERSAILLES STREET AURORA CO 80015 IT SERVICES 256599 INTEGRATED PHYSICIANS NETWORK 1913 S 88TH STREET SUPERIOR CO 80027 SOFTWARE LICENSE FEES 245413 QUEST DIAGNOSTICS INC 695 S BROADWAY DENVER CO 80209 LABORATORY SERVICES 229893 MOJOS CLEANING SERVICES 11352 E 111TH AVENUE HENDERSON CO 80640 JANITORIAL SERVICES 203872 COLORADO PATHOLOGY CONSULTANTS PO BOX 840274 DALLAS TX 75284 PATHOLOGY SERVICES 202552 11 89036 10514096 2746667 2100005 13349799 PATIENT SERVICE REVENUE 621110 25111215 25111215 PHARMACY REVENUE 621110 1215916 1215916 26327131 1177 1177 48 0 48 48 48 OTHER REVENUE 900099 334604 334604 334604 40012759 26327131 0 335829 1030623 1030623 23601944 20238273 3224341 139330 380350 262361 115291 2698 2588661 1551123 1022960 14578 1825215 1219418 595411 10386 7904 932 6599 373 45223 5334 37756 2133 1947191 1332528 599586 15077 100238 14182 84740 1316 764232 103566 641919 18747 320870 47950 272396 524 1174409 105976 1067136 1297 135379 56743 75465 3171 53433 22396 29785 1252 23934 23934 1179837 760415 419422 73018 6959 65364 695 MEDICAL SUPPLIES 3831088 3831088 MISCELLANEOUS 236382 33888 200032 2462 EDUCATION 221201 90244 125475 5482 EQUIPMENT RENTAL & REPA 189999 19253 170517 229 181291 22961 152063 6267 39912422 29725590 9960815 226017 6171318 6528762 596266 632025 542036 522642 2287941 2843733 47218 39344 66048 107752 27124661 7294606 20459408 19830055 10650 10650 30180885 30514963 2369881 2702686 46245 51157 843254 739278 3259380 3493121 X 26468434 26677381 453071 344461 26921505 27021842 30180885 30514963 100337 0 X 0 1 X 1 1 1 X 16287462 14868113 16328812 15091658 13349799 75925844 16287462 14868113 16328812 15091658 13349799 75925844 75925844 15127 9831 5954 3641 1177 35730 3190 12798 35927 218472 334604 604991 76566565 95498251 0.99160 0.99570 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME HONORARIUM MEDICAL RECORDS MEDICAID APPLICATIONS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 22357 22357 39664048 39686405 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 10292 10658 18808 22357 62115 250000 250000 250000 250000 1000000 1500000 0 0 0 4300781 4300781 17913905 3836238 14077667 4909975 3458368 1451607 19830055 X 40439664 318296 542928 861224 39578440 434319 434319 40012759 40230718 318296 318296 39912422 0 39912422 PART X, LINE 2: THE ORGANIZATION QUALIFIES AS A TAX-EXEMPT CORPORATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION IS NOT A PRIVATE FOUNDATION, AND CONTRIBUTIONS TO THE ORGANIZATION QUALIFY AS CHARITABLE TAX DEDUCTIONS BY THE CONTRIBUTOR. THE ORGANIZATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX PROVISIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS OR AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. THE TAX RETURNS FOR THE YEARS 2012, 2013 AND 2014 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 542,928. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 434,319. X X X X X 1 0 0 0 0 0 0 0 0 SIMON G SMITH PRESIDENT & CEO 157762 0 10000 0 0 0 3388 0 30905 0 202055 0 0 0 SEAN C SAUNDERS CFO THROUGH 8/4/2014 158379 0 0 0 61755 0 1808 0 4794 0 226736 0 0 0 KAREN FUNK VP OF CLINICAL SERVICES 211976 0 0 0 0 0 4473 0 30959 0 247408 0 0 0 JUSTIN D WHEELER VP OF CLINICAL SERVICES 206163 0 0 0 0 0 2190 0 28423 0 236776 0 0 0 AN T NGUYEN VP OF DENTAL SERVICES 154291 0 0 0 0 0 3090 0 6873 0 164254 0 0 0 PHILIP J KEPPELER PHYSICIAN 234905 0 0 0 0 0 1116 0 25146 0 261167 0 0 0 CHRISTOPHER J KEENAN PHYSICIAN 225498 0 0 0 0 0 4597 0 13604 0 243699 0 0 0 COLLEEN KEPNER PHYSICIAN 231754 0 0 0 0 0 5158 0 6738 0 243650 0 0 0 JESSICA KENERSON PHYSICIAN 219048 0 0 0 0 0 4665 0 12198 0 235911 0 0 0 EDWARD L FARRELL PHYSICIAN 193102 0 0 0 0 0 3973 0 17767 0 214842 0 0 0 PART I, LINE 4A SEAN C. SAUNDERS - SEVERANCE PAYMENT - $61,755 X 1 1936951 FMV X SOFTWARE 1 163054 FMV 0 0 1 0 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS REVIEWED THE FORM 990 PRIOR TO IT BEING FILED WITH THE IRS. THE CFO REVIEWED THE FORM 990 AND PRESENTED IT TO THE BOARD'S FINANCE COMMITTEE BEFORE IT WAS PRESENTED TO THE FULL BOARD. THE REVIEW INCLUDED A RECONCILIATION OF THE FORM 990 INFORMATION TO THE DATA IN THE AUDITED FINANCIAL STATEMENTS AND A COMPARISON OF THE DATA TO PRIOR YEAR FINANCIAL STATEMENTS TO CONFIRM REASONABLENESS. FORM 990, PART VI, SECTION B, LINE 12C NEW EMPLOYEES AND BOARD MEMBERS RECEIVE TRAINING AND ARE ASKED TO SIGN A CONFLICT OF INTEREST DISCLOSURE FORM ON THE FIRST DAY OF EMPLOYMENT OR SERVICE, AND THEN ANNUALLY. ALL EMPLOYEES AND BOARD MEMBERS ARE INFORMED OF THEIR OBLIGATION TO IMMEDIATELY REPORT ANY CONFLICTS WHEN THEY OCCUR OUTSIDE OF THE ANNUAL PROCESS. THE COMPLIANCE OFFICER, CFO, AND/OR CEO REVIEWS ANY CONFLICTS IDENTIFIED AND A WRITTEN MANAGEMENT PLAN IS DEVELOPED, SIGNED BY THE EMPLOYEE AND HIS/HER MANAGER, AND REMAINS A PART OF THE EMPLOYEE'S HR FILE. ANY VIOLATIONS OF THE WRITTEN MANAGEMENT PLAN WILL RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION. NO EMPLOYEE, OFFICER, DIRECTOR OR AGENT OF THE ORGANIZATION CAN PARTICIPATE IN THE SELECTION OF A CONTRACT, INCLUDING PURCHASE ORDERS, OR IN THE ADMINISTRATION OF A CONTRACT, IF A REAL OR APPARENT CONFLICT OF INTEREST EXISTS. ALL SUPPLIERS COMPLETE A SUPPLIER CONFLICT OF INTEREST DISCLOSURE. EXCEPTIONS MAY BE APPROVED BY THE CEO OR CFO. THE EXCEPTION IS DOCUMENTED AND APPROPRIATELY DISCLOSED. MONITORING OF THE CONFLICTS OF INTEREST POLICY IS A STANDARD BOARD OF DIRECTORS MEETING AGENDA ITEM. BOARD MEMBERS IDENTIFY POTENTIAL CONFLICTS OF INTEREST BEFORE THE BOARD MEETING COMMENCES SO THAT THEY CAN BE ADDED TO THE AGENDA. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS' COMPENSATION COMMITTEE DETERMINED THE COMPENSATION OF THE CEO BY ANALYSIS OF MARKET SALARY INFORMATION PROVIDED BY MOUNTAIN STATES EMPLOYERS COUNCIL, MEDICAL GROUP MANAGEMENT ASSOCIATION, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND CCHN. THE DISCUSSION/DELIBERATION WAS DOCUMENTED IN THE BOD COMPENSATION COMMITTEE NOTES AND BOD MINUTES AND A PAYROLL NOTE WITH BOD APPROVAL. THE ORGANIZATION USED A COMPENSATION CONSULTANT REFERRED BY MOUNTAIN STATES EMPLOYERS COUNCIL TO DETERMINE COMPENSATION OF OTHER OFFICERS, KEY EMPLOYEES, AND CERTAIN OTHER EMPLOYEES OF THE ORGANIZATION. THE CONSULTANT REVIEWED THE ORGANIZATION'S STRATEGIC OBJECTIVES, RELEVANT POLICIES AND PROCEDURES AND CURRENT COMPENSATION DOCUMENTATION. THE CONSULTANT USED SURVEYS AND OTHER INFORMATION TO DEVELOP UP-TO-DATE MARKET INFORMATION BASED ON THE DETAILED JOB DESCRIPTIONS PROVIDED BY THE ORGANIZATION. THE CONSULTANT DEVELOPED BASE COMPENSATION SALARY RANGES, INCLUDING COST ANALYSIS FOR PAY ADJUSTMENTS TO THOSE SALARIES FALLING OUTSIDE THE RANGE. THE LAST COMPENSATION ANALYSIS WAS PERFORMED IN 2013. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST.