Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
333 LAWS AVENUE
Suite
Room/suite
City or town, state or country, and ZIP + 4
UKIAH, CA95482
D Employer identification number

68-0259045
E Telephone number

G Gross receipts $ 27,611,445
F Name and address of principal officer:
LINNEA HUNTER CEO
333 LAWS AVE
UKIAH,CA95482
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.mchcinc.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1992
M State of legal domicile: CA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: THE ORGANIZATION IS A FEDERALLY QUALIFIED HEALTH CENTER THAT PROVIDES HEALTH CARE AND EDUCATION SERVICES THROUGH CLINICS LOCATED IN UKIAH, WILLITS, AND LAKEPORT, CA. SEE SCHEDULE O FOR MORE INFORMATION.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 10
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 10
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 270
6 Total number of volunteers (estimate if necessary) ............. 6 12
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 4,748,689 6,171,536
9 Program service revenue (Part VIII, line 2g) ......... 20,363,146 21,423,195
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... -186,119 16,714
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 0 0
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 24,925,716 27,611,445
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 3,800 5,585
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 17,168,686 18,810,669
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet71,430    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 6,445,121 6,803,861
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 23,617,607 25,620,115
19 Revenue less expenses. Subtract line 18 from line 12....... 1,308,109 1,991,330
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 12,716,237 14,017,600
21 Total liabilities (Part X, line 26)............. 7,673,020 6,983,053
22 Net assets or fund balances. Subtract line 21 from line 20..... 5,043,217 7,034,547
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: TO PROVIDE ACCESS TO EXCELLENT HEALTHCARE SERVICES FOR THE MOST VULNERABLE PEOPLE IN OUR COMMUNITY.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 11,226,860 including grants of $   ) (Revenue $ 12,948,032 )
PRIMARY MEDICAL SERVICES OUR HEALTH CENTERS GRAPPLE WITH THE MOST FUNDAMENTAL HEALTH PROBLEMS BESETTING OUR COMMUNITIES. ALMOST ONE-THIRD OF OUR PATIENTS HAVE SOME FORM OF CHRONIC ILLNESS, AND THE OVERWHELMING NUMBERS OF THESE INDIVIDUALS HAVE MULTIPLE DISORDERS. THE ORGANIZATION IS INVOLVED IN ONGOING STRATEGIC ASSESSMENT OF OUR COUNTIES HEALTH CARE NEEDS AND IT RESPONDS WITH AGILITY BY INSTITUTING INNOVATIVE HEALTH PROGRAMS. DURING THE FISCAL YEAR, THE ORGANIZATION HAD 91,414 PATIENT ENCOUNTERS RELATED TO MEDICAL CARE. SEE SCHEDULE O FOR MORE INFORMATION.
4b (Code:   ) (Expenses $ 3,535,582 including grants of $   ) (Revenue $ 4,077,616 )
DENTAL CARE THE UNINSURED AND UNDERINSURED OF MENDOCINO AND LAKE COUNTIES CONTINUE TO HAVE SERIOUS ACCESS PROBLEMS FOR THEIR ORAL HEALTH NEEDS. OUR DENTAL DEPARTMENT IS ONE OF OUR FASTEST GROWING SERVICES. DURING THE FISCAL YEAR, THE ORGANIZATION HAD 29,429 PATIENT ENCOUNTERS RELATED TO DENTAL CARE. SEE SCHEDULE O FOR MORE INFORMATION.
4c (Code:   ) (Expenses $ 2,149,497 including grants of $   ) (Revenue $ 2,479,032 )
MENTAL HEALTH CARE MENDOCINO PROVIDES MENTAL HEALTH CARE SERVICES, INCLUDING PRIMARY CARE CONSULTATIONS, COUNSELING AND PSYCHOTHERAPY. DURING THE FISCAL YEAR, THE ORGANIZATION HAD 16,531 PATIENT ENCOUNTERS RELATED TO MENTAL HEALTH CARE. SEE SCHEDULE O FOR MORE INFORMATION.
4d Other program services (Describe in Schedule O.)
(Expenses $ 1,663,489 including grants of $ 5,585 ) (Revenue $ 1,918,515 )
4e Total program service expensesMediumBullet18,575,428
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
 
No
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
Yes
 
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
 
No
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............. Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................
34
 
No
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2...
35b
 
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2.............
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
50
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
270
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
10
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
10
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
CA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletTIMOTHY J DOLAN CFO333 LAWS AVENUEUKIAHCA95482 (707) 472-4584
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) JOHN PAVONI........................................................................
CHAIR
 4.0
.......................   		X   X       0 0 0
(2) GERALD CHANEY........................................................................
DIRECTOR BEGINNING 09/2012
 1.0
.......................   		X           0 0 0
(3) BARBARA NEWELL........................................................................
SECRETARY/TREASURER
 1.0
.......................   		X   X       0 0 0
(4) CARLOS FRAUSTO........................................................................
DIRECTOR
 1.0
.......................   		X           0 0 0
(5) BILL MERGENER........................................................................
DIRECTOR
 1.0
.......................   		X           0 0 0
(6) ANNE CAVIGLIA........................................................................
DIRECTOR
 1.0
.......................   		X           0 0 0
(7) JIM MARILL........................................................................
DIRECTOR
 1.0
.......................   		X           0 0 0
(8) JACQUELINE WILLIAMS........................................................................
DIRECTOR BEGINNING 08/2012
 1.0
.......................   		X           0 0 0
(9) JANE BERRY........................................................................
DIRECTOR BEGINNING 12/2012
 1.0
.......................   		X           0 0 0
(10) WAYNE MENGER........................................................................
DIRECTOR BEGINNING 01/2013
 1.0
.......................   		X           0 0 0
(11) MARYLOU LEONARD........................................................................
DIRECTOR THROUGH 10/2012
 1.0
.......................   		X           0 0 0
(12) ROBERT O'CONNELL........................................................................
VICE CHAIR THROUGH 11/2012
 1.0
.......................   		X   X       0 0 0
(13) LINNEA HUNTER........................................................................
CEO
 40.0
.......................   		    X       212,041 0 6,022
(14) TIMOTHY J DOLAN........................................................................
CFO
 40.0
.......................   		    X       110,938 0 5,983
(15) KAREN CRABTREE........................................................................
OB DIRECTOR
 40.0
.......................   		      X     349,868 0 5,983
(16) DOUG LEWIS........................................................................
DENTAL DIRECTOR
 40.0
.......................   		      X     160,037 0 8,579
(17) STEPHEN VANCE........................................................................
MEDICAL DIR THROUGH 3/2013
 40.0
.......................   		      X     328,374 0 5,983
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) JEFF WIEDENFELD........................................................................
CIO
 40.0
.......................   		        X   151,245 0 2,882
(19) MICHAEL MABANGLO........................................................................
BEHAVIORAL HEALTH DIRECTOR
 40.0
.......................   		        X   166,441 0 8,579
(20) MARLENE QUILALA........................................................................
PHYSICIAN
 36.0
.......................   		        X   221,396 0 0
(21) SILVINA HOLASEK........................................................................
PHYSICIAN
 40.0
.......................   		        X   218,618 0 8,579
(22) STEVEN WIRTH........................................................................
PHYSICIAN
 40.0
.......................   		        X   188,579 0 8,579
















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 2,107,537 0 61,169
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet23
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
R C CONSTRUCTION,   CONSTRUCTION 1,282,653
BKD LLP,   AUDIT/TAX/CONSULTING 121,001
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet2
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e 5,960,073
f All other contributions, gifts, grants, and
similar amounts not included above1f 		211,463
g Noncash contributions included in lines
1a-1f:$ 		113,540
h Total. Add lines 1a-1f.......MediumBullet 6,171,536
Program Service Revenue Business Code
2a PATIENT SERVICE 624100 20,599,617 20,599,617    
b EHR INCENTIVE REVENUE 624100 448,750 448,750    
c CONTRACTED MEDICAL SERVICES 624100 38,950 38,950    
d MEDICAL RECORDS 900099 7,612 7,612    
e OTHER 624100 328,266 328,266    
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 21,423,195
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 1,514     1,514
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   15,200
b Less: cost or other basis and sales expenses    
c Gain or (loss)   15,200
d Net gain or (loss)..........MediumBullet 15,200     15,200
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 0
12 Total revenue. See Instructions......MediumBullet 27,611,445 21,423,195   16,714
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 5,585 5,585
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 1,193,808 858,824 334,984  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 14,460,985 10,909,407 3,489,701 61,877
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 0      
9 Other employee benefits ....... 1,963,231 1,480,252 478,529 4,450
10 Payroll taxes ........... 1,192,645 896,851 290,691 5,103
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 21,012   21,012  
c Accounting ........... 115,972   115,972  
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 924,998 774,724 150,274  
12 Advertising and promotion .... 157,397   157,397  
13 Office expenses ....... 1,381,226 965,939 415,287  
14 Information technology ...... 479,756   479,756  
15 Royalties .. 0      
16 Occupancy ........... 432,523 320,725 111,798  
17 Travel ............ 126,548 1,172 125,376  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 306,175   306,175  
20 Interest ........... 208,688 191,657 17,031  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 881,220 637,747 243,473  
23 Insurance .............. 151,356 52,580 98,776  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES & DRUGS 1,139,139 1,139,139    
b BAD DEBT 256,102 256,102    
c LICENSES, DUES, SUBSCRIPTIONS 117,045 23,455 93,590  
d RECRUITING & RETENTION 84,078 61,269 22,809  
e All other expenses 20,626   20,626  
25 Total functional expenses. Add lines 1 through 24e 25,620,115 18,575,428 6,973,257 71,430
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 2,891 1 12,354
2 Savings and temporary cash investments ......... 819,770 2 1,449,246
3 Pledges and grants receivable, net ........... 792,698 3 168,264
4 Accounts receivable, net ............. 1,956,088 4 1,987,760
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 40,153 8 48,193
9 Prepaid expenses and deferred charges .......... 324,748 9 169,879
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 14,809,392
b Less: accumulated depreciation ..... 10b 5,085,665 8,028,389 10c 9,723,727
11 Investments—publicly traded securities .......... 0 11 0
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 751,500 15 458,177
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 12,716,237 16 14,017,600
Liabilities 17 Accounts payable and accrued expenses ......... 1,988,632 17 2,254,713
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 5,684,388 23 4,728,340
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 0 25 0
26 Total liabilities. Add lines 17 through 25......... 7,673,020 26 6,983,053
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 5,042,870 27 7,034,195
28 Temporarily restricted net assets ........... 347 28 352
29 Permanently restricted net assets ........... 0 29 0
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 5,043,217 33 7,034,547
34 Total liabilities and net assets/fund balances ........ 12,716,237 34 14,017,600
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
27,611,445
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
25,620,115
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
1,991,330
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
5,043,217
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
 
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
7,034,547
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
Yes
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . 3,356,528 3,929,295 5,414,703 4,748,689 6,171,536 23,620,751
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... 17,046,625 15,692,472 18,316,988 20,363,146 21,423,195 92,842,426
3 Gross receipts from activities that are not an unrelated trade or business under section 513..           0
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...           0
5 The value of services or facilities furnished by a governmental unit to the organization without charge..           0
6 Total. Add lines 1 through 5. 20,403,153 19,621,767 23,731,691 25,111,835 27,594,731 116,463,177
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...           0
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.           0
c Add lines 7a and 7b..           0
8 Public support (Subtract line 7c from line 6.)           116,463,177
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6... 20,403,153 19,621,767 23,731,691 25,111,835 27,594,731 116,463,177
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 9,656 4,209 1,111 706 1,514 17,196
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.           0
c Add lines 10a and 10b. 9,656 4,209 1,111 706 1,514 17,196
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.           0
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..           0
13 Total support. (Add lines 9, 10c, 11, and 12.).. 20,412,809 19,625,976 23,732,802 25,112,541 27,596,245 116,480,373
14
Section C. Computation of Public Support Percentage
15
15
99.985 %
16
16
99.977 %
Section D. Computation of Investment Income Percentage
17
17
0.015 %
18
18
0.023 %
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
  		Employer identification number

68-0259045
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
  		Employer identification number

68-0259045
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
  		Employer identification number

68-0259045
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2012


Schedule C (Form 990 or 990-EZ) 2012
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
 
j
Total. Add lines 1c through 1i ...............................
 
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
OTHER LOBBYING ACTIVITIES SCHEDULE C, PART II-B, LINE 1(I) THE ORGANIZATION PAYS DUES TO THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS (NACHC) AND THE CALIFORNIA PRIMARY CARE ASSOCIATION (CPCA). A PORTION OF THESE DUES MAY BE USED FOR LOBBYING PURPOSES.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   792,155 792,155
b Buildings ................   8,505,105 2,680,465 5,824,640
c Leasehold improvements ............        
d Equipment ................   2,959,415 1,883,660 1,075,755
e Other .................   2,552,717 521,540 2,031,177
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 9,723,727
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet  
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1 27,340,143
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d -256,102
e Add lines 2a through 2d ..................... 2e -256,102
3 Subtract line 2e from line 1..................... 3 27,596,245
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b 15,200
c Add lines 4a and 4b....................... 4c 15,200
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 27,611,445
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1 25,348,813
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d -15,200
e Add lines 2a through 2d...................... 2e -15,200
3 Subtract line 2e from line 1..................... 3 25,364,013
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b 256,102
c Add lines 4a and 4b....................... 4c 256,102
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 25,620,115
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
UNCERTAIN TAX POSITIONS SCHEDULE D, PART X, LINE 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.
OTHER REVENUE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12 SCHEDULE D, PART XI, LINE 2D $(256,102) BAD DEBT
OTHER REVENUE INCLUDED ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1 SCHEDULE D, PART XI, LINE 4B $ 15,200 LOSS ON SALE OF FIXED ASSETS
OTHER EXPENSE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25 SCHEDULE D, PART XII, LINE 2D $( 15,200) LOSS ON SALE OF FIXED ASSETS
OTHER EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1 SCHEDULE D, PART XII, LINE 4B $ 256,102 BAD DEBT
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)LINNEA HUNTERCEO (i)
(ii)		 212,041
0 		0
0 		0
0 		0
0 		6,022
0 		218,063
0 		0
0
(2)JEFF WIEDENFELDCIO (i)
(ii)		 151,245
0 		0
0 		0
0 		0
0 		2,882
0 		154,127
0 		0
0
(3)KAREN CRABTREEOB DIRECTOR (i)
(ii)		 349,868
0 		0
0 		0
0 		0
0 		5,983
0 		355,851
0 		0
0
(4)DOUG LEWISDENTAL DIRECTOR (i)
(ii)		 160,037
0 		0
0 		0
0 		0
0 		8,579
0 		168,616
0 		0
0
(5)MICHAEL MABANGLOBEHAVIORAL HEALTH DIRECTOR (i)
(ii)		 166,441
0 		0
0 		0
0 		0
0 		8,579
0 		175,020
0 		0
0
(6)STEPHEN VANCEMEDICAL DIR THROUGH 3/2013 (i)
(ii)		 328,374
0 		0
0 		0
0 		0
0 		5,983
0 		334,357
0 		0
0
(7)MARLENE QUILALAPHYSICIAN (i)
(ii)		 153,696
0 		67,700
0 		0
0 		0
0 		0
0 		221,396
0 		0
0
(8)SILVINA HOLASEKPHYSICIAN (i)
(ii)		 182,208
0 		36,410
0 		0
0 		0
0 		8,579
0 		227,197
0 		0
0
(9)STEVEN WIRTHPHYSICIAN (i)
(ii)		 188,579
0 		0
0 		0
0 		0
0 		8,579
0 		197,158
0 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
BONUSES SCHEDULE J, PART II, COLUMN B ALL BONUSES REPORTED ON SCHEDULE J ARE INCENTIVE BONUSES BASED ON THE PROVIDER'S PRODUCTIVITY. BONUSES ARE CALCULATED BASED ON FIXED FORMULAS SPECIFIED IN THE PROVIDERS' CONTRACTS.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies . X 2 113,540 FMV
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) (2012)
Schedule M (Form 990) (2012)
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Identifier Return Reference Explanation
NUMBER OF CONTRIBUTIONS SCHEDULE M, PART I, LINE 20, COLUMN B THE NUMBER OF CONTRIBUTIONS LISTED IS THE NUMBER OF CONTRIBUTORS.
Schedule M (Form 990) (2012)
Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
MENDOCINO COMMUNITY HEALTH CLINIC INC
 
Employer identification number

68-0259045
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990, PART I, LINE 1 OUR VISION: WE ENSURE THAT THERE ARE NO CLOSED DOORS FOR THOSE SEEKING PRIMARY HEALTH CARE AT MENDOCINO COMMUNITY HEALTH CLINIC ("MCHC") IN LAKE AND MENDOCINO COUNTIES. EXCELLENCE, ACCESS, COMMUNITY AND COMPASSION ARE THE VALUES OF OUR ORGANIZATION. OUR GOALS: OUR PATIENTS ARE AS HEALTHY AS POSSIBLE: - THEY HAVE ACCESS TO SERVICES REGARDLESS OF THEIR ABILITY TO PAY. - THEY ARE WELL-INFORMED. - THEY HAVE A SIGNIFICANT VOICE IN THEIR HEALTHCARE CHOICES. - THEY RECOGNIZE THEIR ABILITY TO IMPACT THEIR OWN HEALTH. MCHC IS AN EXTRAORDINARILY POSITIVE PLACE TO WORK: - WE ARE COMMITTED TO OUR MISSION AND VISION. - WE PRODUCE EXCEPTIONAL CLINICAL RESULTS THROUGH IMPLEMENTATION OF BEST MEDICAL PRACTICES. - WE ARE HIGHLY PROFESSIONAL AND SEEK CAREER DEVELOPMENT OPPORTUNITIES. - WE DEMONSTRATE OUR CUSTOMER SERVICE PHILOSOPHY WHEN INTERACTING WITH PATIENTS AND EACH OTHER. - WE WORK TOGETHER TO GENERATE SUSTAINABLE FINANCIAL RESULTS. THE COMMUNITY LOOKS TO MCHC FOR HEALTH CARE LEADERSHIP: - MCHC IS RECOGNIZED AND SUPPORTED AS A VALUABLE COMMUNITY RESOURCE. - MCHC COLLABORATES WITH OTHER HEALTH PRACTITIONERS TO IMPROVE THE HEALTH OF OUR COMMUNITY. - MCHC IS CONSULTED REGARDING HEALTH POLICY ISSUES ON A LOCAL, STATE AND NATIONAL LEVEL. - MCHC'S BOARD OF DIRECTORS ARE ACTIVELY INVOLVED IN THEIR COMMUNITIES. OUR CORE OPERATING PRINCIPLES: - WE BELIEVE THAT HEALTH CARE IS A RIGHT AND A RESPONSIBILITY. - WE DELIVER PRIMARY HEALTH CARE IN A SUPPORTIVE, SAFE AND NONJUDGMENTAL MANNER, STRESSING PATIENT INVOLVEMENT. - WE ENSURE THAT LIMITED FUNDS ARE USED EFFECTIVELY. - WE BELIEVE IT IS THE RESPONSIBILITY OF MANAGEMENT TO CREATE A PRODUCTIVE AND POSITIVE WORKING ENVIRONMENT FOR ALL STAFF BY MODELING EFFECTIVE COLLABORATION AND COMMUNICATION AT ALL LEVELS. - WE ACCEPT RESPONSIBILITY FOR OURSELVES. - WE BELIEVE THAT TRUST IS EARNED. - WE EMPHASIZE PROFESSIONAL TRAINING AND DEVELOPMENT OF ALL STAFF. - WE BELIEVE THAT HAPPY PEOPLE TREAT EACH OTHER WELL AND THAT FUN LEADS TO CREATIVITY.
VOLUNTEERS FORM 990, PART I, LINE 6 THE ORGANIZATION'S BOARD OF DIRECTORS IS A VOLUNTEER BOARD.
PRIMARY MEDICAL CARE FORM 990, PART III, LINE 4A MEDICAL CARE THE ORGANIZATION IS INVOLVED IN ONGOING STRATEGIC ASSESSMENT OF OUR COUNTIES' HEALTH CARE NEEDS AND IT RESPONDS WITH AGILITY BY INSTITUTING INNOVATIVE HEALTH PROGRAMS. OUR PATIENTS ARE OFFERED COMPREHENSIVE PRIMARY CARE MEDICAL SERVICES, INCLUDING PHYSICAL EXAMS, CHRONIC DISEASE MANAGEMENT SERVICES, HEALTH MAINTENANCE SUPPORT, VACCINES, IMMUNIZATIONS, INCISION/DRAINAGE OF CYSTS, OUTPATIENT HIV TESTING AND CARE, WELL-CHILD CARE, CHILD HEALTH AND DISABILITY PROGRAM EXAMS, ADDICTION MEDICINE, SCREENINGS FOR ANEMIA, LEAD, VISION, HEARING AND TUBERCULOSIS. SERVICES ARE OFFERED IN BOTH ENGLISH AND SPANISH. OTHER SPECIAL CLINICAL INITIATIVES INCLUDE OFFSITE SERVICES TO POPULATIONS WITH SPECIAL BARRIERS TO CARE INCLUDING SENIORS IN SKILLED NURSING FACILITIES AND THE HOMELESS; AN ORGANIZATION-WIDE PURSUIT OF SOLUTIONS TO MANAGEMENT OF DIABETES, HIV AND EARLY CANCER DETECTION; AND THE DEVELOPMENT OF COLLABORATIVE RESPONSES TO WIDE-RANGING HEALTH THREATS SUCH AS MRSA. WE HAVE DEVELOPED STRONG ALLIANCES WITH SPECIALTY CARE PROVIDERS IN ALL OUR COMMUNITIES, GIVING OUR PATIENTS THE ABILITY TO HAVE CARE FOR THEIR UNIQUE HEALTH CHALLENGES. CURRENT SPECIALTIES INCLUDE CHIROPRACTIC, DERMATOLOGY, NUTRITION EDUCATION, GASTROINTESTINAL MEDICINE, OPHTHALMOLOGY, ORTHOPEDICS, PEDIATRICS, PODIATRY, PSYCHIATRY AND SURGERY. CHRONIC DISEASE MANAGEMENT DIABETES, CANCER AND HIV/AIDS ARE THE KINDS OF SERIOUS ILLNESSES AFFECTING OUR PATIENTS. IN A VARIETY OF WAYS WE GRAPPLE WITH MEETING SHORT-TERM AND LONG-TERM TREATMENT NEEDS OF THESE MORE FRAGILE PATIENTS. MCHC HAS ACTIVELY PARTICIPATED IN IMPLEMENTING THE HEALTH DISPARITIES COLLABORATIVE MODEL OF CARE. WE CURRENTLY PARTICIPATE IN DIABETES, CANCER SCREENING, AND HIV COLLABORATIVES. THESE PROJECTS USE PATIENT REGISTRIES AND CLINICAL GUIDELINES TO IMPROVE OUR PROVISION OF CARE. DR. BILL FISHER TAKES AN ACTIVE ROLE IN OUR CANCER COLLABORATIVE WORK AS A PHYSICIAN CHAMPION. ON A DAY-TO-DAY BASIS, WE EXTEND SUPPORT TO OUR PATIENTS THROUGH OUR CASE MANAGERS. CASE MANAGERS WORK WITH THE CLINICAL TEAM TO HELP FORMULATE COST EFFECTIVE CARE PLANS. THESE CARE COORDINATING STAFF MEMBERS ALSO TAKE ON THE TASK OF IDENTIFYING A PATIENT'S UNIQUE NEEDS AND THEN HELP CONNECT THEM TO COMMUNITY SERVICES THAT MAY FILL IMMEDIATE NEEDS FOR NUTRITION, SHELTER AND TRANSPORTATION. MCHC IS PROUD THAT ITS CARE FOR ITS PATIENTS DOES NOT END AT THE DOOR, AND THAT OUR YEARS OF COMMUNITY COLLABORATION HAVE STRENGTHENED THE COMMUNITY'S SAFETY NET SO IT EFFICIENTLY PROTECTS ITS MOST VULNERABLE POPULATIONS.
DENTAL CARE FORM 990, PART III, LINE 4B AT ALL THREE SITES, MCHC OFFERS COMPREHENSIVE DENTAL SERVICES TO ITS PATIENTS. IN ADDITION TO EXAMS, PATIENTS ARE OFFERED ACCESS TO GUM TREATMENT, SEALANTS, TOOTH-COLORED FILLINGS, DENTURES AND EMERGENCY CARE. SPECIAL PROGRAMS INCLUDE HIV DENTAL CARE, A NURSING FACILITY DENTAL OUTREACH PROGRAM, ORAL HEALTH CARE FOR PREGNANT WOMEN AND A COMMITMENT TO COMMUNITY OUTREACH THAT ALLOWS MCHC TO IMPLEMENT SHORT-TERM, COMMUNITY BASED SERVICE PROJECTS INCLUDING ON-SITE SCREENINGS AT MIGRANT EDUCATION SCHOOLS. WE ARE ONE OF THE FEW HEALTH FACILITIES IN NORTHERN CALIFORNIA THAT SPECIALIZES IN ORAL CARE FOR THE DEVELOPMENTALLY DISABLED. ADDITIONALLY, WE REFER PATIENTS IN NEED OF ORAL SURGERY TO A NETWORK OF SPECIALISTS IN THE NORTHERN CALIFORNIA REGION. WE CONTINUE TO PURSUE, AND RECEIVE, GRANT FUNDING TO FOCUS ON THIS PROBLEM. CONSEQUENTLY, WE ARE ACTIVELY RECRUITING DENTISTS COMMITTED TO SERVICE WHO WISH TO WORK IN A FAST-PACED TEAM ENVIRONMENT.
MENTAL HEALTH CARE FORM 990, PART III, LINE 4C IN OUR PRACTICE, MANY OF OUR PATIENTS ARE BESET BY MULTIPLE CONDITIONS. FOR EXAMPLE, A SENIOR STRUGGLING WITH THE EFFECTS OF DIABETES MAY SUFFER FROM CHRONIC DEPRESSION OR A MOTHER SEEKING CARE AT OUR WOMEN'S HEALTH UNIT MAY BE A VICTIM OF ABUSE. AT MCHC, WE SEEK TO TREAT THE WHOLE PERSON. PRIMARY CARE CONSULTATION (PCC) PCC IS AN INTEGRATED PRIMARY CARE/BEHAVIORAL HEALTH PROGRAM DESIGNED TO SERVE PATIENTS WHOSE HEALTH IS AFFECTED BY STRESS, WHO HAVE PROBLEMS MAINTAINING HEALTHY LIFESTYLES AND/OR THOSE AFFECTED BY PSYCHOLOGICAL DISORDERS. THE PCC MODEL ENCOURAGES MEDICAL AND MENTAL HEALTH PROVIDERS TO COLLABORATE AND UNDERSTAND THE PATIENT HOLISTICALLY, AN APPROACH THAT IS BROADLY ADVOCATED WITHIN THE DISCIPLINES OF FAMILY MEDICINE, SOCIAL WORK AND PSYCHIATRY. PSYCHOTHERAPY MCHC'S PSYCHOTHERAPY DEPARTMENT PROVIDES OUTPATIENT PSYCHOTHERAPY AND COUNSELING SERVICES. ELIGIBLE PATIENTS ARE REFERRED TO ONE OF OUR PSYCHIATRISTS, LICENSED PSYCHOLOGISTS OR LICENSED CLINICAL SOCIAL WORKERS WHO PROVIDE SERVICES AT OUR CENTERS.
OTHER PROGRAM SERVICES FORM 990, PART III, LINE 4D PHARMACY/OTHER SERVICES PEOPLE IN GREATEST NEED CANNOT CONSISTENTLY ACCESS AFFORDABLE MEDICATIONS. THOSE WHO ARE LOW INCOME, UNINSURED AND/OR HAVE CHRONIC CONDITIONS ARE MOST SEVERELY IMPACTED BY LACK OF ACCESS TO AFFORDABLE MEDICATIONS. BECAUSE OF ITS ORGANIZATIONAL COMMITMENT TO ACCESS, MCHC HAS A FULL-TIME, LICENSED, BILINGUAL PHARMACIST AT HILLSIDE HEALTH CENTER. BY MAINTAINING A FULL-SERVICE PHARMACY, MCHC CAN MAKE LIFE-SAVING MEDICATIONS AVAILABLE TO LOW-INCOME PATIENTS AT REDUCED FEES. MCHC ALSO PARTICIPATES IN THE 340B DISCOUNTED DRUG PROGRAM AND OTHER PROGRAMS THAT PROVIDE FREE MEDICATIONS TO ELIGIBLE USERS. WOMEN'S HEALTH SERVICES CARE FOR HER, AN INNOVATIVE, BY-WOMEN, FOR-WOMEN HEALTH UNIT, WAS ESTABLISHED IN 2002. IT PROVIDES COMPREHENSIVE WOMEN'S HEALTH SERVICES IN A SENSITIVE AND SUPPORTIVE ENVIRONMENT. THE PROGRAM'S STAFFING MODEL RELIES ON CERTIFIED NURSE-MIDWIVES AND FAMILY NURSE-PRACTITIONERS WHO HAVE ACCESS TO A BROAD ARRAY OF SUPPORT STAFF, INCLUDING WOMEN'S HEALTH SPECIALISTS, NURSES, HEALTH EDUCATORS, NUTRITIONISTS, BREASTFEEDING SPECIALISTS, CANCER SPECIALISTS AND LAB TECHNICIANS. CARE FOR HER PROVIDES WOMEN WITH FULL-SCOPE GYNECOLOGY SERVICES, PAP SMEARS, FOLLOW UP FOR ABNORMAL PAPS AND COLPOSCOPIES; INFORMATION AND EDUCATION ABOUT SEXUALLY-TRANSMITTED INFECTIONS, NUTRITION AND SMOKING CESSATION; GENETIC SCREENING AND COUNSELING; BLOOD TESTS, INCLUDING THYROID, DIABETES, CHOLESTEROL AND HORMONAL EVALUATIONS; URINALYSIS; BONE DENSITY/DEXASCAN; MAMMOGRAMS; CANCER SCREENINGS. MCHC IS PROUD OF OUR PREGNANCY CARE PROGRAM. A SEAMLESSLY BILINGUAL STAFF OF PROFESSIONAL WOMEN HAVE CREATED A HOMELIKE ENVIRONMENT WHERE WOMEN MAY COME TO PREPARE FOR THE BIRTH OF THEIR CHILD. PRENATAL EDUCATION CLASSES CREATE A LEARNING ENVIRONMENT THAT ALLOWS FAMILIES TO FURTHER DEVELOP CHILD-REARING SKILLS. CARE FOR HER OFFERS HANDS-ON INDIVIDUALIZED EDUCATION FOR THE PREGNANT MOTHERS ENTERING OUR PRACTICE. IN OUR EXPERIENCE, EXPECTANT MOTHERS WELCOME THE OPPORTUNITY TO IMPROVE THEIR SKILLS. WE KNOW THIS ONE-ON-ONE EDUCATION SUPPORTS THE GROWING FAMILIES IN OUR COMMUNITIES. CLASSES INCLUDE PREGNANCY EDUCATION, PARENTING SKILLS, NUTRITION, FAMILY PLANNING, DIABETES, INFANT CARE, BREAST-FEEDING AND EARLY CHILDHOOD DEVELOPMENT. PATIENT FINANCIAL SERVICES (PFS) BECAUSE WE KNOW THAT ACCESSING SUPPORT FOR HEALTH CARE CAN BE DIFFICULT, WE HAVE A STRONG PATIENT FINANCIAL SERVICES STAFF TRAINED TO HELP PATIENTS NAVIGATE PUBLIC INSURANCE PROGRAM APPLICATIONS. THEY ARE KNOWLEDGEABLE ADVOCATES WHO ASSIST OUR PATIENTS IN ACCESSING AFFORDABLE HEALTH CARE. IN ADDITION TO PFS REPRESENTATIVES, MCHC OFFERS ACCESS TO A FAMILY ASSISTANCE REPRESENTATIVE (FAR) FROM COUNTY SOCIAL SERVICES. THIS COLLABORATIVE SERVICE IS AVAILABLE TO OUR PATIENTS AT EACH OF OUR CENTERS, EXPEDITING PROCESSING OF PROGRAM APPLICATIONS AND ENSURING THAT ELIGIBLE PATIENTS MAY OBTAIN HEALTHCARE BENEFITS IN A TIMELY MANNER. CENTERS, EXPEDITING PROCESSING OF PROGRAM APPLICATIONS AND ENSURING THAT ELIGIBLE PATIENTS MAY OBTAIN HEALTHCARE BENEFITS IN A TIMELY MANNER. ADDITIONALLY, THE ORGANIZATION PROVIDES A SMALL AMOUNT OF GRANTS AND ASSISTANCE TO OTHER ORGANIZATIONS.
CHANGES TO GOVERNING DOCUMENTS FORM 990, PART VI, SECTION A, LINE 4 THE ORGANIZATION AMENDED ITS BYLAWS TO INCLUDE THE FOLLOWING: THE PRESIDENT/CEO IS AN AGENT OF THE BOARD AND, AS SUCH, IS DIRECTLY ACCOUNTABLE TO THE BOARD; THE PRESIDENT/CEO IS AN EX OFFICIO MEMBER OF THE BOARD. ADDITIONAL RESPONSIBILITIES OF THE BOARD ARE OUTLINED BELOW: - APPROVAL OF THE ANNUAL 330 GRANT APPLICATION - MONITORING AND MAINTAINING COMPLIANCE THROUGH THE CLINIC CORPORATE COMPLIANCE PROGRAM - EVALUATING ITSELF FOR EFFICIENCY, EFFECTIVENESS, AND COMPLIANCE WITH ALL SECTION 330 REQUIREMENTS, WHICH WILL BE DONE EVERY TWO YEARS - MAINTAINING CONFIDENTIALITY REGARDING BOARD BUSINESS - UNDERSTANDING THAT MEMBERS MAY NOT SPEAK OR ACT ON BEHALF OF THE BOARD WITHOUT OBTAINING PRIOR CONSENT THE COMPOSITION OF THE BOARD OF DIRECTORS WAS AMENDED TO INCLUDE THE FOLLOWING: - ALL BOARD MEMBERS MUST MEET FEDERAL REQUIREMENTS FOR SERVICE AND USER-MEMBERS SHALL BE SELECTED IN A MANNER THAT IS CONSISTENT WITH APPLICABLE LAWS AND REGULATIONS - THE BOARD HAS THE SOLE AUTHORITY TO ELECT/REJECT ITS MEMBERS AND NO THIRD PARTY SHALL HAVE THE ABILITY TO SELECT REPRESENTATIVES TO SERVE ON THE BOARD - BOARD MEMBER-CONSUMERS WILL UTILIZE THE HEALTH CENTER AS THEIR PRINCIPAL SOURCE OF CARE AND SHALL HAVE USED THOSE SERVICES IN THE LAST TWO YEARS - A LEGAL GUARDIAN OF A CONSUMER WHO IS A DEPENDENT CHILD OR ADULT, OR WHO IS A LEGAL SPONSOR OF AN IMMIGRANT CONSUMER, MAY BE CONSIDERED A CONSUMER AND MAY SERVE ON THE GOVERNING BOARD - NO MEMBER OF THE BOARD SHALL BE A DOMESTIC PARTNER OF AN EMPLOYEE THE ORGANIZATION ADDED A CONFLICT OF INTEREST STATEMENT TO THE BYLAWS. UPON APPOINTMENT OF THE BOARD OF DIRECTORS, NEW MEMBERS WILL ATTEST TO THE FOLLOWING: - CONFIDENTIALITY FIDUCIARY STATEMENT - CONFLICT OF INTEREST STATEMENT - CODE OF CONDUCT STATEMENT ALL BOARD MEMBERS WILL ATTEST TO THE CONFLICT OF INTEREST STATEMENT ANNUALLY. A MINIMUM OF SIX MONTHS MUST SEPARATE EMPLOYMENT WITH THE ORGANIZATION AND JOINING THE BOARD IN ORDER TO AVOID ANY CONFLICTS OF INTEREST. THE ORGANIZATION CHANGED TO FOLLOWING RELATING TO OFFICER DUTIES: - THE SECRETARY/TREASURER SHALL ENSURE MINUTES ARE DISTRIBUTED TO ALL BOARD MEMBERS. THE SECRETARY SHALL SIGN THE MINUTES TO VERIFY ACCEPTANCE, AND SIGNED COPIES OF THE MINUTES SHALL BE KEPT IN THE PRINCIPAL OFFICE OF THE ORGANIZATION. THE BOARD MAY DECLARE THE OFFICE OF ANY OFFICER VACANT FOR THE FOLLOWING CAUSES: - THE OFFICER HAS BEEN DECLARED OF UNSOUND MIND BY A COURT ORDER - THE OFFICER HAS BEEN CONVICTED OF A FELONY - THE OFFICER HAS BEEN FOUND GUILTY OF BREACHING ANY DUTY ARISING UNDER ARTICLE 3 OF THE CALIFORNIA NONPROFIT PUBLIC BENEFIT CORPORATION LAW - THE OFFICER HAS MISSED THREE CONSECUTIVE MEETINGS THE VICE CHAIR WILL AUTOMATICALLY SUCCEED THE CHAIR IF THE CHAIR POSITION BECOMES VACANT. SHOULD ANY OTHER OFFICE BE VACATED, THE MAJORITY OF THE BOARD SHALL APPOINT A MEMBER IN GOOD STANDING TO TAKE THE POSITION. BOARD MEMBERS SHALL COMPRISE A MAJORITY OF EACH STANDING COMMITTEE. VOTING MEMBERS OF THE FINANCE COMMITTEE MUST BE LESS THAN FIFTY PERCENT OF THE BOARD. THE BYLAWS WERE AMENDED TO CHANGE THE FOLLOWING FISCAL POLICIES: - REMOVAL OF THE STIPULATION THAT "ANY BOARD MEMBER WITH A FINANCIAL INTEREST IN THE HEALTH CENTER" SHALL NOT SERVE ON THE AUDIT COMMITTEE. - THE AUDIT COMMITTEE SETS THE COMPENSATION OF BOTH THE CHIEF EXECUTIVE OFFICER AND THE CHIEF FINANCIAL OFFICER.
PROCESS TO REVIEW THE FORM 990 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. PRIOR TO BEING FILED, THE FORM 990 IS REVIEWED BY THE CEO AND CFO. THE FULL BOARD WILL RECEIVE A COPY OF THE 990 PRIOR TO IT BEING FILED WITH THE IRS.
MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A COMPLIANCE OFFICER IN PLACE WHO MONITORS THE ADHERENCE TO THE POLICY RELATED TO CONFLICTS OF INTEREST. THIS POLICY IS INCLUDED IN EMPLOYEE HANDBOOK AND COVERS ALL EMPLOYEES AND BOARD MEMBERS. IF A CONFLICT OF INTEREST IS IDENTIFIED WITHIN THE BOARD, THE INTERESTED PARTY WOULD RECUSE HIMSELF OR HERSELF FROM ANY MATTER UNDER WHICH THE CONFLICT OPERATES. TO THE ORGANIZATION'S KNOWLEDGE, THERE ARE NO SUCH CONFLICTS AT THIS TIME.
COMPENSATION REVIEW FORM 990, PART VI, SECTION B, LINES 15A & 15B THE CEO AND CFO'S COMPENSATION ARE REVIEWED BY THE ORGANIZATION'S BOARD OF DIRECTORS ANNUALLY. THE REVIEW INCLUDES AN ANALYSIS BY THE AUDIT COMMITTEE OF THE BOARD UTILIZING COMPARABILITY DATA FROM NACHC SURVEYS. THE ANALYSIS AND RECOMMENDATION WAS PRESENTED TO THE FULL BOARD AND APPROVED. THIS APPROVAL WAS DOCUMENTED IN THE BOARD MINUTES.
DISCLOSURE OF DOCUMENTS FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO BE MAILED UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

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