CHIPPEWA VALLEY HOSPITAL & OAKVIEW CARE CENTER INC: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- CHIPPEWA VALLEY HOSPITAL & OAKVIEW CARE CENTER INC (EIN 39-1365168)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-11-10
- IRS object ID
- 201713149349301666
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-11-10T10:24:06-06:00 | ReturnTs |
| Tax Period End | 2016-12-31 | TaxPeriodEndDt |
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391365168 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHIPPEWA VALLEY HOSPITAL AND | BusinessNameLine1Txt |
| Business Name Line2 | OAKVIEW CARE CENTER INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CHIP | BusinessNameControlTxt |
| Phone | 7156724211 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1220 THIRD AVENUE WEST | AddressLine1Txt |
| City | DURAND | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54736 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Lynn C Addiscott | PersonNm |
| Person Title | Asst. Secretary | PersonTitleTxt |
| Phone | 4079751492 | PhoneNum |
| Signature | 2017-10-30 | SignatureDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 204.139.85.142 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-10-30 | IPDt |
| IP Tm | 15:45:34 | IPTm |
| IP Timezone | ED | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | C18440E83583A01A3D3F74DEBC89B245B68C7147 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | F7F973113C6C6A5F5987F0EC85E73F6D0608CD2F | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Chippewa Valley Hospital | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DOUGLAS PETERSON | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1220 THIRD AVENUE WEST | AddressLine1Txt |
| City | DURAND | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54736 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $15,389,607 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.chippewavalleyhospital.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1980 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | THE OPERATION OF A 25 BED ACUTE CARE HOSPITAL. | ActivityOrMissionDesc |
| Voting Members Governing Body | 12 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 125 | TotalEmployeeCnt |
| Total Volunteers | 13 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $60,047 | PYContributionsGrantsAmt |
| CY Contributions Grants | $105,772 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $12,585,599 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $15,263,727 | CYProgramServiceRevenueAmt |
| PY Investment Income | $264,709 | PYInvestmentIncomeAmt |
| CY Investment Income | $7,173 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $12,910,355 | PYTotalRevenueAmt |
| CY Total Revenue | $15,376,672 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $193 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $8,425,400 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,828,202 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $6,020,505 | PYOtherExpensesAmt |
| CY Other Expenses | $5,977,337 | CYOtherExpensesAmt |
| PY Total Expenses | $14,445,905 | PYTotalExpensesAmt |
| CY Total Expenses | $13,805,732 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$1,535,550 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,570,940 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $5,342,096 | TotalAssetsBOYAmt |
| Total Assets EOY | $6,946,302 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,546,803 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,718,057 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | -$1,204,707 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $228,245 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | Adventist Health System Sunbelt Healthcare Corporation and all its subsidiary organizations were established by the Seventh-Day Adventist Church to bring a ministry of healing and health to the communities served. Our mission is to extend the healing ministry of Christ.The hospital and healthcare system whose parent is Adventist Health System Sunbelt Healthcare Corporation is known as Adventist Health System (AHS). AHS seeks to be widely respected as a consumer-focused organization that engages individuals in their health by delivering wholistic, best practice care across a connected, comprehensive continuum of services. With Christ as our example, AHS cares for and nurtures people: our employees, our communities, our healthcare professionals, and those who trust us for care and healing. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $12,292,322 | ExpenseAmt |
| Grant | $193 | GrantAmt |
| Revenue | $15,263,727 | RevenueAmt |
| Desc | OPERATION OF A 25-BED ACUTE CARE HOSPITAL IN DURAND, WISCONSIN. DURING THE CURRENT YEAR THERE WERE 324 PATIENT ADMISSIONS RESULTING IN 1,822 PATIENT DAYS and 9,129 outpatient visits for the year. | Desc |
| Total Program Service Expenses | $12,292,322 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| Info In Schedule O Part V | Yes (X) | InfoInScheduleOPartVInd |
| IRP Document | 18 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 125 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 12 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Karsten Randolph | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9136762152 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 9100 W 74th Street | AddressLine1Txt |
| City | Shawnee Mission | CityNm |
| State Abbreviation | KS | StateAbbreviationCd |
| ZIP | 66204 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (19 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Former Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd |
|---|---|---|---|---|---|---|---|---|---|
| Bacon Kenneth | |||||||||
| Chairman/Dir (Beg 1/16) | 1.50 | 48.50 | Yes (X) | $0 | $913,624 | $110,364 | |||
| Bauer Linda | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Bechel Todd | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Best Roxanne | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Buhlman Carol | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Dohlman MD Robert | |||||||||
| director | 50.00 | 0.00 | Yes (X) | $229,253 | $0 | $19,256 | |||
| Edge Michael | |||||||||
| Vice Chairman | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Gilles Mark | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Heike Robert | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Peterson Douglas R | |||||||||
| Director/CEO | 50.00 | 0.00 | Yes (X) | $0 | $454,952 | $73,519 | Yes (X) | ||
| Randolph Karsten G | |||||||||
| Director (Beg 2/16) | 3.70 | 46.30 | Yes (X) | $0 | $475,459 | $92,312 | Yes (X) | ||
| Yingst William | |||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Rucker MD Kenneth | |||||||||
| Physician | 50.00 | 0.00 | $309,500 | $0 | $25,215 | Yes (X) | |||
| Arhinful MD Enoch | |||||||||
| Physician | 50.00 | 0.00 | $251,138 | $0 | $29,432 | Yes (X) | |||
| Brahmbhatt MD Vismay | |||||||||
| Physician | 50.00 | 0.00 | $189,640 | $0 | $27,088 | Yes (X) | |||
| Mentele Anton P | |||||||||
| CRNA | 50.00 | 0.00 | $182,825 | $0 | $8,393 | Yes (X) | |||
| Poeschel Jane | |||||||||
| FNPC | 50.00 | 0.00 | $153,380 | $0 | $26,101 | Yes (X) | |||
| Mayzell MD George | |||||||||
| Former Region CMO | 0.00 | 0.00 | $0 | $308,091 | $51,544 | Yes (X) | |||
| Wehtje Ronald | |||||||||
| Former Region CFO | 0.00 | 36.00 | $0 | $191,666 | $14,324 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,315,736 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $2,343,792 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $477,548 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 8 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | Yes (1) | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Acute CARE Inc | |||||
| 1609 N Ankeny Blvd | Ankeny | IA | 50023 | Physician Services | $1,026,382 |
| Physical Therapy Association | |||||
| PO Box 173 | Durand | WI | 54736 | Physical Therapy Services | $677,735 |
| Readylink | |||||
| PO Box 1047 | Thousand Palms | CA | 92276 | Nurse Staffing | $136,702 |
| Computer Medical Imaging | |||||
| 719 W Hamilton Ave B | Eau Claire | WI | 54701 | Radiology Services | $131,282 |
| Shared Medical Services | |||||
| PO Box 330 | Cottage Grove | IL | 53527 | MRI | $110,075 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 5 | CntrctRcvdGreaterThan100KCnt |
| Info In Schedule O Part VIII | Yes (X) | InfoInScheduleOPartVIIIInd |
| Government Grants | $100,579 | GovernmentGrantsAmt |
| All Other Contributions | $5,193 | AllOtherContributionsAmt |
| Total Contributions | $105,772 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Net Patient Revenue | 622110 | $15,138,759 | $15,138,759 |
| Rental Revenue | 622110 | $66,256 | $66,256 |
| Lifeline revenue | 622110 | $37,413 | $37,413 |
| Cafeteria Revenue | 622110 | $16,022 | $16,022 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $5,277 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $5,277 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $15,263,727 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $20,108 | TotalRevenueColumnAmt |
| Exclusion | $20,108 | ExclusionAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $12,935 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -$12,935 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$12,935 | TotalRevenueColumnAmt |
| Exclusion | -$12,935 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,376,672 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $15,263,727 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $7,173 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $193 | TotalAmt |
| Program Services | $193 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $819,563 | TotalAmt |
| Management And General | $819,563 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,732,764 | TotalAmt |
| Program Services | $4,732,764 | ProgramServicesAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $224,963 | TotalAmt |
| Program Services | $215,787 | ProgramServicesAmt |
| Management And General | $9,176 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,676,561 | TotalAmt |
| Program Services | $1,664,211 | ProgramServicesAmt |
| Management And General | $12,350 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $374,351 | TotalAmt |
| Program Services | $359,082 | ProgramServicesAmt |
| Management And General | $15,269 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,557 | TotalAmt |
| Management And General | $2,557 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,238 | TotalAmt |
| Management And General | $22,238 | ManagementAndGeneralAmt |
Fees For Srvc Invst Mgmnt Fees FeesForSrvcInvstMgmntFeesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,173 | TotalAmt |
| Management And General | $5,173 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,101,576 | TotalAmt |
| Program Services | $2,871,334 | ProgramServicesAmt |
| Management And General | $230,242 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,053 | TotalAmt |
| Management And General | $13,053 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $547,891 | TotalAmt |
| Program Services | $452,512 | ProgramServicesAmt |
| Management And General | $95,379 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $687,242 | TotalAmt |
| Program Services | $569,230 | ProgramServicesAmt |
| Management And General | $118,012 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $250,278 | TotalAmt |
| Program Services | $250,278 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $85,391 | TotalAmt |
| Program Services | $7,887 | ProgramServicesAmt |
| Management And General | $77,504 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,723 | TotalAmt |
| Management And General | $5,723 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $156,840 | TotalAmt |
| Program Services | $156,840 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,577 | TotalAmt |
| Program Services | $1,577 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $62,911 | TotalAmt |
| Program Services | $49,333 | ProgramServicesAmt |
| Management And General | $13,578 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $608,011 | $608,011 | |
| REPAIRS & MAINTENANCE | $332,560 | $332,560 | |
| Licenses & Permits | $73,593 | $73,593 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $20,723 | TotalAmt |
| Program Services | $20,723 | ProgramServicesAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,805,732 | TotalAmt |
| Program Services | $12,292,322 | ProgramServicesAmt |
| Management And General | $1,513,410 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $311,251 | BOYAmt |
| EOY | $2,057,776 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,324,173 | BOYAmt |
| EOY | $1,876,454 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $122,673 | BOYAmt |
| EOY | $134,350 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $293,421 | BOYAmt |
| EOY | $283,757 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $112,071 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $0 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $112,071 | BOYAmt |
| EOY | $112,071 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,178,507 | BOYAmt |
| EOY | $2,481,894 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,342,096 | BOYAmt |
| EOY | $6,946,302 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $799,764 | BOYAmt |
| EOY | $1,402,525 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,747,039 | BOYAmt |
| EOY | $5,315,532 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,546,803 | BOYAmt |
| EOY | $6,718,057 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$1,819,935 | BOYAmt |
| EOY | -$386,983 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $615,228 | BOYAmt |
| EOY | $615,228 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$1,204,707 | BOYAmt |
| EOY | $228,245 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,342,096 | BOYAmt |
| EOY | $6,946,302 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,570,940 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$61,725 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | -$76,263 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $893 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $893 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part II-B, Line 1: | FormAndLineReferenceDesc |
| Explanation | Member dues paid to the American Hospital Association and the Wisconsin Hospital Association that represent lobbying activities conducted by these two associations. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $112,071 | OtherCostOrOtherBasisAmt |
| Book Value | $112,071 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $112,071 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (2 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| DUE FROM Affiliated | $2,473,506 |
| OTHER CURRENT RECEIVABLES | $8,388 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $2,481,894 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (4 entries)
| DescDesc | AmtAmt |
|---|---|
| DUE TO Affiliated | $173,198 |
| Payable to Third Parties | $922,291 |
| Interco Alloc of TE Bond Proceeds | $4,202,969 |
| CREDIT BALANCES IN AR | $17,074 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $5,315,532 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part X, Line 2: | FormAndLineReferenceDesc |
| Explanation | The filing organization is a subsidiary organization within Adventist Health System (AHS). The consolidated financial statements of AHS contain the following FIN 48 footnote: Please note that dollar amounts are in thousands. Healthcare Corporation and its affiliated organizations, other than North American Health Services, Inc. and its subsidiary (NAHS), are exempt from state and federal income taxes. Accordingly, Healthcare Corporation and its tax-exempt affiliates are not subject to federal, state or local income taxes except for any net unrelated business taxable income. NAHS is a wholly owned, for-profit subsidiary of Healthcare Corporation. NAHS and its subsidiary are subject to federal and state income taxes. NAHS files a consolidated federal income tax return and, where appropriate, consolidated state income tax returns. All taxable income was fully offset by net operating loss carryforwards for federal income tax purposes; as such, there is no provision for current federal or state income tax for the years ended December 31, 2016 and 2015. NAHS also has temporary deductible differences of approximately $59,100 and $62,700 at December 31, 2016 and 2015, respectively, primarily as a result of net operating loss carryforwards. At December 31, 2016, NAHS had net operating loss carryforwards of approximately $59,600, expiring beginning in 2022 through 2026. Deferred taxes have been provided for these amounts, resulting in a net deferred tax asset of approximately $22,500 and $23,800 at December 31, 2016 and 2015, respectively. A full valuation allowance has been provided at December 31, 2016 and 2015 to offset the deferred tax asset since Healthcare Corporation has determined that it is more likely than not that the benefit of the net operating loss carryforwards will not be realized in future years. The Income Taxes Topic of the ASC (ASC 740) prescribes the accounting for uncertainty in income tax positions recognized in financial statements. ASC 740 prescribes a recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken, or expected to be taken, in a tax return. There were no material uncertain tax positions as of December 31, 2016 and 2015. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCareInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | 0 | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $75,130 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $75,130 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00540 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $700,087 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $415,428 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $284,659 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02060 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $775,217 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $415,428 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $359,789 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02600 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $775,217 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $415,428 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $359,789 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02600 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $273,348 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $471 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $7,801,507 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $7,724,265 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $77,242 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Chippewa Valley Hospital and Oakview Care Center Inc | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1220 Third Ave West | AddressLine1Txt |
| City | Durand | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54736 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.chippewavalleyhospital.com | WebsiteAddressTxt |
| State License | 1008 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Chippewa Valley Hospital | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 16 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | See Statement | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 14 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | See Statement | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SEE STATEMENT | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SEE STATEMENT | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SEE STATEMENT | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Chippewa Valley Hospital | Part V, Section B, Line 5: Chippewa Valley Hospital and Oakview Care Center, Inc. (the Hospital) serves as the only hospital in Pepin County, Wisconsin. It is a 25-bed Critical Access Hospital. In conducting its 2016 Community Health Needs Assessment, the Hospital worked directly and collaboratively with the Pepin County Health Department. Pepin County in its entirety comprises the Hospital's service area. Pepin County is a racially homogenous community, with 98% of the residents being white and only 2% being other races. The Durand City Service Area, located in Pepin County, has been designated by the Federal Government as a "Medically Underserved Area/Population". The Hospital offers a breadth of safety net services that serve a critical role in healthcare delivery to this community and all other communities within Pepin County. To provide broad community input with respect to the conduct of its 2016 Community Health Needs Assessment, the Hospital, in cooperation with the Pepin County Health Department, created a Committee of Community Health Improvement Process Stakeholders (CHIPS). The CHIPS Committee included representatives from the Hospital and its clinics and community participants that represented low-income, minority, and underserved populations. The listing of community participants in the CHIPS Committee follows:Pepin County Health DepartmentPepin County Board of HealthHeike PharmacyWestern Wisconsin CaresPepin ManorPepin County Sheriff's DepartmentDurand Police DepartmentPepin County Human ServicesPepin County Aging and Disability Resource CenterPepin County Counsel of Senior CitizensPepin County GovernmentDurand School DistrictPepin County UW ExtensionAssisted Living of DurandUniversity of Wisconsin, Eau ClairePepin County Nutrition CoalitionDurand Fire DepartmentDurand Emergency Medical Services.All efforts were made to assure appropriate assessment of and inclusion of leaders, representatives, or members of medically underserved, low-income, and minority populations and populations with chronic disease needs in the community served by the Hospital. These efforts included the following:1. Individuals and entities serving on the CHIPS Committee were representative of individuals with low income and/or disabilities (Western Wisconsin Cares, Pepin County Human Services, Pepin County Aging and Disability Resource Center).2. The Pepin County Health Department and Pepin County Board of Health with expertise in Pepin County chronic disease issues served on the CHIPS Committee.3. Providers who manage individuals in the Hospital's community who are low income, minority and who have chronic disease issues served on the CHIPS Committee.4. Representative Community Members served on the CHIPS committee. |
| Chippewa Valley Hospital | Part V, Section B, Line 7d: The Hospital has adopted a policy that addresses the public posting requirements of the Community Health Needs Assessment. Under this policy, the Community Health Needs Assessment Reports must be posted on the Hospital's website at least until the date the hospital facility has made widely available on its website its two subsequent Community Health Needs Assessment Reports. The Hospital will also make a paper copy of its Community Health Needs Assessment Report available for public inspection upon request and without charge, at least until the date the hospital facility has made available for public inspection its two subsequent Community Health Needs Assessment Reports. |
| Chippewa Valley Hospital | Part V, Section B, Line 11: The information provided below explains how the hospital facility addressed in 2016 the significant health needs identified in its 2013 Community Health Needs Assessment, and any such needs that were not addressed and the reasons why such needs were not addressed. The hospital facility conducted a Community Health Needs Assessment in 2016 and adopted an implementation strategy to address the significant health needs identified in the 2016 Community Health Needs Assessment in 2017 prior to May 15, 2017.Chippewa Valley Hospital (CVH or "the Hospital") is a 25-bed Critical Access Hospital located in Duran, WI, a tiny rural community of 1,900 people. This is the third-year update for CVH's 2013-2016 Community Health Plan/Implementation Strategy. The Hospital developed this Plan and posted it in May 2014 as part of its 2013 Community Health Needs Assessment process.For the development of both the Community Health Needs Assessment and the Community Health Plan/Implementation Strategy, Chippewa Valley Hospital made a notable effort to define and address the needs of low-income, minority and underserved populations in its service area. The 2013 Community Health Needs Assessment used primary data interviews and surveys; and hospital prevalence data to help the Hospital determine the health needs of the community it serves.Once the data was gathered, the primary issues identified in the Needs Assessment were prioritized by community and hospital stakeholders, who then selected key issues for the Hospital to address in its 2013-2016 Community Health Plan.The three-year progress on the Community Health Plan is noted below. The narrative describes the issues identified in 2013 and give an update on the strategies addressing those issues. There is also a description of the identified issues that the Hospital is not addressing. The hospital's 2013 Community Health Needs Assessment was conducted in partnership with the Pepin County Health Department. The Assessment identified chronic disease, substance abuse, healthy lifestyle and communicable disease as the community's major issues. The hospital worked with its Board, the Pepin County Health Department and Pepin County EMS to develop implementation strategies to address these needs.Priority Issue: Chronic Disease Management2013 Description of the Issue: Chronic conditions are defined as conditions that are long-term, do not go away on their own, are rarely healed and can result in disability of some form. Examples are heart disease, chronic kidney disease and diabetes; they are the leading causes of both death and disability in the United States. Preventive measures to curb chronic disease may be implemented with relative ease, and the impact of implementing preventive measures is of high value both to individuals and to the community at large. 2016 Update: Chippewa Valley Hospital took lab testing on the road to the community. The hospital went to all businesses in the community and offered routine lab tests that included Cholesterol, Triglycerides, HDL, LDL and CLDL tests. This was offered free of charge to everyone. An education handout was provided related to the chronic conditions identified in the 2013 Needs Assessment. Nearly 350 community members participated. The hospital again sponsored educational forums on Depression in cooperation with the Durand Ministerial Society and a local church. Priority Issue: Alcohol and Other Substance Abuse2013 Description of the Issue: Wisconsin ranks above the national average in the percentage of alcohol use among adults at roughly 79%; the national average is 55%. According to Wisconsin Healthiest People 2020, alcohol-related deaths are the fourth leading cause of death in Wisconsin. Alcohol or drug abuse may lead to motor vehicle and other injuries; fetal alcohol spectrum disorder and other childhood disorders; alcohol- and drug-dependence; liver, brain, heart and other diseases; infections; family problems; and both nonviolent and violent crimes. Unhealthy alcohol and drug use means any use of a substance that result in negative consequences. These substances include alcohol, prescription drugs and illegal mood altering substances. 2016 Update: Chippewa Valley Hospital does not offer mental health or substance abuse services, but did offer numerous educational programs on Alcohol/Substance Abuse and Tobacco Abuse. With the Health Department and the Ministerial Association, the hospital also helped develop and disseminate hundreds of interdisciplinary educational materials both in the hospital and at community events. Priority Issue: Healthy Growth and Development (Food, Nutrition and Physical Activity)2013 Description of the Issue: Wisconsin's rate of adult obesity increased from 20 percent to 26 percent between 2000 and 2008 (Wisconsin Department of Health Services, Track 2010). Food, nutrition and physical activity were identified by Health Department's Community Health Improvement Plans (CHIPs) as a necessary component of any improvement plan in light of the impact these factors have on Chronic Disease Management. The Health Department noted that specific and purposeful goals and objectives would improve general health, prevent chronic disease, and improve the quality of life for those individuals already living with chronic disease.2016 Update: Chippewa Valley Hospital offered ongoing educational forums on chronic disease. The forums included information on obesity and diabetes, and the forum leaders disseminated educational materials provided by the Pepin County Health Department. In addition, the hospital offers (Adventist Health System's) CREATION Health programming, which focuses on wellness and lifestyle: Choice, Rest, Environment, Activity, Trust in God, Interpersonal Relationships, Outlook and Nutrition. Chippewa Valley Hospital presented the CREATION Health program to several area civic groups and churches, and gave additional training to its staff. The HealthConnect Newsletter at Chippewa Valley Hospital is distributed to nearly 12,000 area homes, and features these topics as well.Priority Issue: Communicable Diseases2013 Description of the Issue: While this indicator was not selected by DOH Community Health Improvement Plan (CHIP) for prioritization, it was later selected independently by Chippewa Valley Hospital for inclusion. While some sub-indicators are low (e.g., the number of selected communicable diseases infecting Pepin County and food-borne and waterborne disease), the age-adjusted mortality rate for influenza/pneumonia is higher than the rest of the Western Region of Wisconsin and the state of Wisconsin overall. The hospital's two primary care physician practices, as well as the Health Department and local Pharmacy, promote and provide immunizations for flu and pneumonia.2016 Update: A joint program with Pepin County Health Department was provided for multiple community members of Hispanic descent who tested positive for TB. They were enrolled in a program where they received proper medications and treatment at reduced rates through the State of Wisconsin program. They also received follow-up care with one of our local healthcare providers.Priorities Considered but Not Selected ObesityRationale: Addressing Healthy Growth and Development will have a direct impact on obesity in the County. Therefore, this measure will not be formally and separately addressed. Environmental and Occupational HealthRationale: Pepin County outcomes are superior to State outcomes in all but one category of exposure (housing with increased lead risk based on % of houses built before 1950). Further, Chippewa Valley Hospital does not offer environmental health services but the Health Department does. Mental HealthRationale: Many of the mental health outcome measures for Wisconsin have positive trends (% of kids grades 9-12 feeling so sad or hopeless that they have stopped doing some usual activities; % of Wisconsin students in grades 9-12 seriously considering attempting suicide). The number of Pepin County residents with suicide listed as the primary cause of death is decreasing. Further, Chippewa Valley Hospital does not offer mental health services. Oral HealthRationale: Not believed to have high impact on overall population health for Pepin County. Further, Chippewa Valley Hospital does not offer oral health services. |
| Part V, Section B, Line 10a | URL for the hospital facility's most recently adopted implementation strategy: http://chippewavalleyhospital.com/aboutus/communitybenefit. |
| Schedule H, Part V, Section B, Line 16a,b,c: | The Financial Assistance Policy can be found at URL:chippewavalleyhospital.com/patientsvisitors/financialassistanceThe Financial Assistance Policy application can be found at:chippewavalleyhospital.com/patientsvisitors/financialassistanceThe plain language summary is available at:chippewavalleyhospital.com/patientsvisitors/financialassistance |
| Part V, Section B, Line 7a: | URL for the hospital facility's most recent CHNA: www.chippewavalleyhospital.com/aboutus/communitybenefit |
| Part V, Section B, Line 8-10a | The filing organization adopted a Community Health Needs Assessment Report by 12/31/16 and was in the process of developing its Community Health Needs Implementation Strategy. The filing organization's 2017 Community Health Needs Implementation Strategy will be documented in a written report called the "Community Health Plan". The Community Health Plan (CHP) will describe how the filing organization plans to meet its identified prioritized health needs or will identify the health need as one the filing organization does not intend to specifically address and provide an explanation as to why the filing organization does not intend to address that health need. In accordance with Final Regulation Section 1.501(r)-3(c)(5), the filing organization's 2017 CHP was adopted no later than May 15, 2017 and is also posted on the hospital facility's website.As the hospital facility's 2017 Community Health Needs Implementation Strategy was not adopted by the end of the hospital organization's taxable year of December 31, 2016, Schedule H, Part V, Section B, line 9 indicates that 2014 was the tax year in which the hospital facility last adopted an implementation strategy. Schedule H, Part V, Section B, Line 10a reflects the website address for the hospital facility's 2014 Implementation Strategy since this is the most recently adopted Implementation Strategy. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 2 - Durand Clinic South | ||||
| 1250 3rd Street Ave West | Durand | WI | 54736 | Outpatient Physician Clinic |
| 3 - Durand Clinic North | ||||
| 905 7th Ave West | Durand | WI | 54736 | Outpatient Physician Clinic |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 6a: | The filing organization was a wholly owned subsidiary of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC) during its current tax year. During the current year, AHSSHC served as a parent organization to 22 tax-exempt 501(c)(3) hospital organizations that operated 44 hospitals in ten states within the U.S. The system of organizations under the control and ownership of AHSSHC is known as "Adventist Health System" (AHS).All hospital organizations within AHS collect, calculate, and report the community benefits they provide to the communities they serve. AHS organizations exist solely to improve and enhance the local communities they serve. AHS has a system-wide community benefits accounting policy that provides guidelines for its health care provider organizations to capture and report the costs of services provided to the underprivileged and to the broader community. Each AHS hospital facility reports their community benefits to their Board of Directors and strives to communicate their community benefits to their local communities. Additionally, the filing organizations most recently conducted community health needs assessment and associated implementation strategy are posted on the filing organization's website. |
| Part I, Line 7: | The amounts of costs reported in the table in line 7 of Part I of Schedule H were determined by utilizing a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges, contained in the Schedule H instructions. |
| Part III, Line 2: | The amount of bad debt expense, reported on line 2 of Section A of Part III is recorded in accordance with Healthcare Financial Management Association Statement No. 15. Discounts and payments on patient accounts are recorded as adjustments to revenue, not bad debt expense. |
| Part III, Line 3: | Methodology for Determining the Estimated Amount of Bad Debt Expense that May Represent Patients who Could Have Qualified under the Filing Organization's Financial Assistance Policy:Self-pay patients may apply for financial assistance by completing a Financial Assistance Application Form (FAA Form). If an individual does not submit a complete FAA Form within 240 days after the first post-discharge billing statement is sent to the individual, an individual may be considered for presumptive eligibility based upon a scoring tool that is designed to classify patients into groups of varying economic means. The scoring tool uses algorithms that incorporate data from credit bureaus, demographic databases, and hospital specific data to infer and classify patients into respective economic means categories. Individuals who earn a certain score on the scoring tool are considered to qualify as eligible for the most generous financial assistance under the filing organization's Financial Assistance Policy. As determined by the filing organization, a nominal amount of such a patient's bill is written off as bad debt expense, while the remaining portion of the patient's bill is considered non-state charity. The amount written off as bad debt expense for those patients who potentially qualify as non-state charity using the scoring tool is the amount shown on line 3 of Section A of Part III. Rationale for Including Certain Bad Debts in Community Benefit:The filing organization is dedicated to the view that medically necessary health care for emergency and non-elective patients should be accessible to all, regardless of age, gender, geographic location, cultural background, physician mobility, or ability to pay. The filing organization treats emergency and non-elective patients regardless of their ability to pay or the availability of third-party coverage. By providing health care to all who require emergency or non-elective care in a non-discriminatory manner, the filing organization is providing health care to the broad community it serves. As a 501(c)(3) hospital organization, the filing organization maintains a 24/7 emergency room providing care to all whom present. When a patient's arrival and/or admission to the facility begins within the Emergency Department, triage and medical screening are always completed prior to registration staff proceeding with the determination of a patient's source of payment. If the patient requires admission and continued non-elective care, the filing organization provides the necessary care regardless of the patient's ability to pay. The filing organization's operation of a 24/7 Emergency Department that accepts all individuals in need of care promotes the health of the community through the provision of care to all whom present. Current Internal Revenue Service guidance that tax-exempt hospitals maintain such emergency rooms was established to ensure that emergency care would be provided to all without discrimination. The treatment of all at the filing organization's Emergency Department is a community benefit. Under the filing organization's Financial Assistance Policy, every effort is made to obtain a patient's necessary financial information to determine eligibility for financial assistance. However, not all patients will cooperate with such efforts and a financial assistance eligibility determination cannot be made based upon information supplied by the individual. In this case, a patient's portion of a bill that remains unpaid for a certain stipulated time period is wholly or partially classified as bad debt. Bad debts associated with patients who have received care through the filing organization's Emergency Department should be considered community benefit as charitable hospitals exist to provide such care in pursuit of their purpose of meeting the need for emergency medical care services available to all in the community. |
| Part III, Line 4: | Financial Statement Footnote Related to Accounts Receivable and Allowance for Uncollectible Accounts:The financial information of the filing organization is included in a consolidated audited financial statement for the current year.The applicable footnote from the attached consolidated audited financial statements that addresses accounts receivable, the allowance for uncollectible accounts, and the provision for bad debts can be found on page 8. Please note that dollar amounts on the attached consolidated audited financial statements are in thousands. |
| Part III, Line 8: | Costing Methodology: Medicare allowable costs were calculated using a cost-to-charge ratio. |
| Part III, Line 9b: | The hospital filing organization's collection practices are in conformity with the requirements set forth in the 2014 Final Regulations regarding the requirements of Internal Revenue Code Section 501(r)(4) - (r)(6). No extraordinary collection actions (ECA's) are initiated by the hospital filing organization in the 120-day period following the date after the first post-discharge billing statement is sent to the individual (or, if later, the specified deadline given in a written notice of actions that may be taken, as described below). Individuals are provided with at least one written notice (notice of actions that may be taken) and a copy of the filing organization's Plain Language Summary of the Financial Assistance Policy that informs the individual that the hospital filing organization may take actions to report adverse information to credit reporting agencies/bureaus if the individual does not submit a Financial Assistance Application Form (FAA Form) or pay the amount due by a specified deadline. The specified deadline is not earlier that 120 days after the first post-discharge billing statement is sent to the individual and is at least 30 days after the notice is provided. A reasonable attempt is also made to orally notify an individual about the filing organization's Financial Assistance Policy and how the individual may obtain assistance with the Financial Assistance application process. If an individual submits an incomplete FAA Form during the 240-day period following the date on which the first post-discharge billing statement was sent to the individual, the hospital filing organization suspends any reporting to consumer credit reporting agencies/bureaus (or ceases any other ECA's) and provides a written notice to the individual describing what additional information or documentation is needed to complete the FAA Form. This written notice contains contact information including the telephone number and physical location of the hospital facility's office or department that can provide information about the Financial Assistance Policy, as well as contact information of the hospital facility's office or department that can provide assistance with the financial assistance application process or, alternatively, a nonprofit organization or governmental agency that can provide assistance with the financial assistance application process if the hospital facility is unable to do so. If an individual submits a complete FAA Form within a reasonable time-period as set forth in the notice described above, the hospital filing organization will suspend any adverse reporting to consumer credit reporting agencies/bureaus until a financial assistance policy eligibility determination can be made. |
| Part VI, Line 2: | The Hospital conducted community health needs assessments (CHNA) during 2013 and 2016. It's 2016 CHNA was adopted by its governing board by December 31, 2016, the end of the Hospital's taxable year in which it conducted the CHNA. The Hospital's 2016 CHNA complied with the guidance set forth by the IRS in Final Regulation Section 1.501(r)-3. In addition to the CHNA discussed above, a variety of practices and processes are in place to ensure that the filing organization is responsive to the health needs of its community.Such practices and processes involve the following:1. A hospital operating/community board composed of individuals broadly representative of the community, community leaders, and those with specialized medical training and expertise;2. Post-discharge patient follow-up related to the on-going care and treatment of patients who suffer from chronic diseases; 3. Sponsorship and participation in community health and wellness activities that reach a broad spectrum of the filing organization's community; and 4. Collaboration with other local community groups to address the health care needs of the filing organization's community. |
| Part VI, Line 3: | The Financial Assistance Policy (FAP), Financial Assistance Application Form (FAA Form), and the Plain Language Summary of the Financial Assistance Policy (PLS) of the filing organization's hospital facility are transparent and available to all individuals served at any point in the care continuum. The FAP, FAA Form, PLS, and contact information for the hospital facility's financial counselors are prominently and conspicuously posted on the filing organization's hospital facility's website. The website indicates that a copy of the FAP, FAA Form, and PLS is available and how to obtain such copies in the primary languages of any populations with limited proficiency in English that constitute the lesser of 1,000 individuals or 5% of the members of the community served by the hospital facility (referred to below as LEP defined populations). Signage is displayed in public locations of the filing organization's hospital facility, including at all points of admission and registration and the Emergency Department. The signage contains the hospital facility's website address where the FAP, FAA Form, and PLS can be accessed and the telephone number and physical location that individuals can call or visit to obtain copies of the FAP, FAA Form and PLS or to obtain more information about the hospital facility's FAP, FAA Form and PLS. Paper copies of the hospital facility's FAP, FAA Form and PLS are available upon request and without charge, both in public locations in the hospital facility and by mail. Paper copies are made available in English and in the primary languages of any LEP defined populations. The filing organization's hospital facility's financial counselors seek to provide personal financial counseling to all individuals admitted to the hospital facility who are classified as self-pay during the course of their hospital stay or at time of discharge to explain the FAP and FAA Form and to provide information concerning other sources of assistance that may be available, such as Medicaid. A paper copy of the hospital facility's PLS will be offered to every patient as a part of the intake or discharge process. A conspicuous written notice is included on all billing statements sent to patients that notifies and informs recipients about the availability of financial assistance under the filing organization's financial assistance policy, including the following: 1) the telephone number of the hospital facility's office or department that can provide information about the FAP and the FAA Form; and 2) the website address where copies of the FAP, FAA Form and PLS may be obtained. Reasonable attempts are made to inform individuals about the hospital facility's FAP in all oral communications regarding the amount due for the individual's care. Copies of the PLS are distributed to members of the community in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance. |
| Part VI, Line 4: | The filing organization is located in rural Durand, Wisconsin. It currently operates a hospital facility and is licensed for 25 acute care beds which are approved as "swing beds" for long term care. Chippewa Valley Hospital (the Hospital) is a crucial community and regional asset. It is the only hospital in Pepin County, Wisconsin with the closest hospital being 20 or more miles away. The Hospital's Service Area, Pepin County, has a population of approximately 7,469, with an estimated 1,337 over the age of 65. The median household income, in Pepin County is approximately $48,446. High school graduates account for approximately 88.5% of Pepin County. Appoximately 51% of the Hospital's patients during the current year were medicare patients, about 5.1% were medicaid patients, about 1.6% were self-pay patients, and the remaining percentage were patients covered under commerical insurance. In the current year, about 31.2% of the Hospital's In-Patients were admitted through the Hospital's Emergency Department. |
| Part VI, Line 5: | The provision of community benefit is central to Chippewa Valley Hospital's mission of service and compassion. Restoring and promoting the health and quality of life of those in the communities served by the Hospital is a function of "extending the healing ministry of Christ and embodies the Hospital's commitment to its values and principles. The Hospital commits substantial resources to provide a broad range of services to both the underprivileged as well as the broader community. In addition to the community benefit and community building information provided in Parts I, and III of this Schedule H, the Hospital captures and reports the benefits provided to its community through faith-based care. Examples of such benefits include the cost associated with chaplaincy care programs and mission peer reviews and mission conferences. During the current year, the hospital provided $85,684 of benefit with respect to the faith-based and spiritual needs of the community in conjunction with its operation of a community hospital. The Hospital also provides benefits to its community's infrastructure by investing in capital improvements to ensure that facilities and technology provide the best possible care to the community. As a faith-based mission-driven community hospital, the Hospital is continually involved in monitoring its community, identifying unmet health care needs and developing solutions and programs to address those needs. In accordance with its conservative approach to fiscal responsibility, surplus funds of the Hospital are continually being invested in resources that improve the availability and quality of delivery of health care services and programs to its community. |
| Part VI, Line 6: | Chippewa Valley Hospital is a part of a faith-based healthcare system of organizations whose parent is Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). The system is known as Adventist Health System (AHS). AHSSHC is an organization exempt from federal income tax under IRC Section 501(c)(3). AHSSHC and its subsidiary organizations operate 44 hospitals in 10 states throughout the U.S., primarily in the Southeastern portion of the U.S. AHSSHC and its subsidiaries also operate 16 nursing home facilities and other ancillary health care provider facilities, such as ambulatory surgery centers and diagnostic imaging centers. As the parent organization of the AHS system, AHSSHC provides executive leadership and other professional support services to its subsidiary organizations. Professional support services include among others corporate compliance, legal, human resources, reimbursement, risk management, and tax as well as treasury functions. The provision of these executive and support services on a centralized basis by AHSSHC provides an appropriate balance between providing each AHS subsidiary hospital organization with mission-driven consistent leadership and support while allowing the hospital organization to focus its resources on meeting the specific health care needs of the community it serves. The reader of this Form 990 should keep in mind that this reporting entity may differ in certain areas from that of a stand-alone hospital organization due to its inclusion in a larger system of healthcare organizations. As a part of a system of hospitals and other health care organizations, the filing organization benefits from reduced costs due to system efficiencies, such as large group purchasing discounts, and the availability of internal resources such as internal legal counsel. Each AHS subsidiary pays a management fee to AHSSHC for the internal services provided by AHSSHC. As a result, management fee expense reported by a AHS subsidiary organization may appear greater in relation to management fee expense that may be reported by a single stand-alone hospital. The single stand-alone hospital would likely report costs associated with management and other professional services on various expense line items in its statement of revenue and expense as opposed to reporting such costs in one overall management fee expense. As the reporting of the Form 990 is done on an entity by entity basis, there is no single Form 990 that captures the programs and operations of AHS as a whole. The reader is directed to visit the web-site of AHS at www.adventisthealthsystem.com to learn more about the mission and operations of AHS. |
| Part VI, Line 7: | The filing organization does not file an annual community benefit report with any state agencies. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Travel For Companions | Yes (X) | TravelForCompanionsInd |
| Idemnification Gross Up Pmts | Yes (X) | IdemnificationGrossUpPmtsInd |
| Discretionary Spending Acct | Yes (X) | DiscretionarySpendingAcctInd |
| Written Policy Ref T And E Expnss | Yes (1) | WrittenPolicyRefTAndEExpnssInd |
| Substantiation Required | Yes (1) | SubstantiationRequiredInd |
| Severance Payment | Yes (1) | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (11 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Bacon Kenneth | ||||||||||||||
| Chairman/Dir (Beg 1/16) | $0 | $482,991 | $0 | $168,080 | $0 | $262,553 | $0 | $64,981 | $0 | $45,383 | $0 | $1,023,988 | $0 | $43,471 |
| Dohlman MD Robert | ||||||||||||||
| director | $220,680 | $0 | $152 | $0 | $8,421 | $0 | $8,942 | $0 | $10,314 | $0 | $248,509 | $0 | $0 | $0 |
| Peterson Douglas R | ||||||||||||||
| Director/CEO | $0 | $182,560 | $0 | $54,140 | $0 | $218,252 | $0 | $22,816 | $0 | $50,703 | $0 | $528,471 | $0 | $8,889 |
| Randolph Karsten G | ||||||||||||||
| Director (Beg 2/16) | $0 | $342,691 | $0 | $85,963 | $0 | $46,805 | $0 | $48,382 | $0 | $43,930 | $0 | $567,771 | $0 | $35,840 |
| Rucker MD Kenneth | ||||||||||||||
| Physician | $288,150 | $0 | $154 | $0 | $21,196 | $0 | $14,388 | $0 | $10,827 | $0 | $334,715 | $0 | $0 | $0 |
| Arhinful MD Enoch | ||||||||||||||
| Physician | $234,209 | $0 | $1,204 | $0 | $15,725 | $0 | $13,524 | $0 | $15,908 | $0 | $280,570 | $0 | $0 | $0 |
| Brahmbhatt MD Vismay | ||||||||||||||
| Physician | $182,971 | $0 | $152 | $0 | $6,517 | $0 | $9,862 | $0 | $17,226 | $0 | $216,728 | $0 | $0 | $0 |
| Mentele Anton P | ||||||||||||||
| CRNA | $105,617 | $0 | $152 | $0 | $77,056 | $0 | $8,341 | $0 | $52 | $0 | $191,218 | $0 | $0 | $0 |
| Poeschel Jane | ||||||||||||||
| FNPC | $89,645 | $0 | $152 | $0 | $63,583 | $0 | $7,670 | $0 | $18,431 | $0 | $179,481 | $0 | $0 | $0 |
| Mayzell MD George | ||||||||||||||
| Former Region CMO | $0 | $0 | $0 | $0 | $0 | $308,091 | $0 | $10,588 | $0 | $40,956 | $0 | $359,635 | $0 | $0 |
| Wehtje Ronald | ||||||||||||||
| Former Region CFO | $0 | $99,322 | $0 | $0 | $0 | $92,344 | $0 | $5,359 | $0 | $8,965 | $0 | $205,990 | $0 | $36,561 |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 1a | The filing organization is a part of the system of healthcare organizations known as Adventist Health System (AHS). Members of the filing organization's executive management team that hold the position of Vice-President or above are compensated by and on the payroll of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the parent organization of AHS. AHSSHC is exempt from federal income tax under IRC Section 501(c)(3). The filing organization reimburses AHSSHC for the salary and benefit cost of those executives on the payroll of AHSSHC that provide services and are on the management team of the filing organization. Travel for companions: AHSSHC has a Corporate Executive Policy that provides a benefit to allow for a traveling AHSSHC executive to have his or her spouse accompany the executive on certain business trips each year. Typically, reimbursement is only provided to Vice Presidents and above and is usually limited to one business trip per year beyond the annual AHS President's Council business meeting and other meetings where the spouse is specifically invited. The AHSSHC Corporate Executive Spousal Travel Policy was originally approved and reviewed by the AHSSHC Board Compensation Committee, an independent body of the AHSSHC Board of Directors. All spousal travel costs reimbursed to the executive are considered taxable compensation to the executive. Tax Indemnification and gross-up payments: AHS has a system-wide policy addressing gross-up payments provided in connection with employer-provided benefits/other taxable items. Under the policy, certain taxable business-related reimbursements (i.e. taxable business-related moving expenses, taxable items provided in connection with employment) provided to any employee may be grossed-up at a 25% rate upon approval of the filing organization's CEO and CFO. Additionally, employees at the Director level and above are eligible for gross-up payments on gifts received for board of director services. Discretionary spending account: A nominal discretionary spending amount was provided in the current year to all eligible executives who attend the annual AHS President's Council business meeting ($500 per executive) or the annual AHS CFO Conference, or CMO/CNO business meeting ($300 per executive). Other discretionary spending accounts may be provided in connection with other AHS sponsored conferences but typically do not exceed $200 per participant. With respect to the AHS President's council meeting, eligible executives may include AHSSHC Vice Presidents and above and all AHSSHC subsidiary organization CEOs and Regional CFOs. The payment provided to each executive was considered taxable compensation to the executive. |
| Part I, Line 3 | The individual who serves as the CEO of the filing organization is compensated by Adventist Health System Sunbelt Healthcare Corporation (AHSSHC) for that individual's role in serving as the CEO. Compensation and benefits provided to this individual are determined pursuant to policies, procedures, and processes of AHSSHC that are designed to ensure compliance with the intermediate sanctions laws as set forth in IRC Section 4958. AHSSHC has taken steps to ensure that processes are in place to satisfy the rebuttable presumption of reasonableness standard as set forth in Treasury Regulation 53.4958-6 with respect to its active executive-level positions. The AHSSHC Board Compensation Committee (the Committee) serves as the governing body for all executive compensation matters. The Committee is composed of certain members of the Board of Directors (the Board) of AHSSHC. Voting members of the Committee include only individuals who serve on the Board as independent representatives of the community, who hold no employment positions with AHSSHC and who do not have relationships with any of the individuals whose compensation is under their review that impacts their best independent judgment as fiduciaries of AHSSHC. The Committee's role is to review and approve all components of the executive compensation plan of AHSSHC. As an independent governing body with respect to executive compensation, it should be noted that the Committee will often confer in executive sessions on matters of compensation policy and policy changes. In such executive sessions, no members of management of AHSSHC are present. The Committee is advised by an independent third party compensation advisor. This advisor prepares all the benchmark studies for the Committee. Compensation levels are benchmarked with a national peer group of other not-for-profit healthcare systems and hospitals of similar size and complexity to AHS and each of its affiliated entities. The following principles guide the establishment of individual executive compensation: - The salary of the President/CEO of AHS will not exceed the 40th percentile of comparable salaries paid by similarly situated organizations; and - Other executive salaries shall be established using market medians. The compensation philosophy, policies, and practices of AHSSHC are consistent with the organization's faith-based mission and conform to applicable laws, regulations, and business practices. As a faith-based organization sponsored by the Seventh-day Adventist Church (the Church), AHSSHC's philosophy and principles with respect to its executive compensation practices reflect the conservative approach of the Church's mission of service and were developed in counsel with the Church's leadership. |
| Part I, Lines 4a-b | During the year ending December 31, 2016, George Mayzell, MD received severance payments in the amount of $295,647. Pursuant to the AHSSHC Corporate Executive Policy governing executive severance, severance agreements for executives operating at the Vice President level and above are entered into upon eligibility to facilitate the transition to subsequent employment following an involuntary separation from employment with AHS. As discussed in Line 1a above, executives on the filing organization's management team that hold the position of Vice-President or above are compensated by and on the payroll of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the parent organization of a healthcare system known as Adventist Health System (AHS). In recognition of the contribution that each executive makes to the success of AHS, AHS provides to eligible executives participation in the AHS Executive FLEX Benefit Program (the Plan). The purpose of the Plan is to offer eligible executives an opportunity to elect from among a variety of supplemental benefits, including deferred compensation benefits taxable under Internal Revenue Code (IRC) Section 457(f), to individually tailor a benefits program appropriate to each executive's needs. The Plan provides eligible participants a pre-determined benefits allowance credit that is equal to a percentage of the executive's base pay from which is deducted the cost of mandatory and elective employee benefits. The pre-determined benefits allowance credit percentage is approved by the AHSSHC Board Compensation Committee, an independent committee of the Board of Directors of AHSSHC. Any funds that remain after the cost of mandatory and elective benefits are subtracted from the annual pre-determined benefits allowance are contributed, at the employee's option, to either an IRC 457(f) deferred compensation account or to an IRC 457(b) eligible deferred compensation plan. Upon attainment of age 65, all previous 457(f) deferred amounts are paid immediately to the participant and any future employer contributions are made quarterly from the Plan directly to the participant. The Plan documents define an employee who is eligible to participate in the Plan to generally include the Chief Executive Officers of AHS entities and Vice Presidents of all AHS entities whose base salary is at least $236,000. The Plan provides for a class year vesting schedule (2 years for each class year) with respect to amounts accumulated in the executive's 457(f) deferred compensation account. Distributions could also be made from the executive's 457(f) deferred compensation account upon attainment of age 65 or upon an involuntary separation. The account is forfeited by the executive upon a voluntary separation. In addition to the Plan, AHS has instituted a defined benefit, non-tax-qualified deferred compensation plan for certain executives who have provided lengthy service to AHS and/or to other Seventh-Day Adventist Church hospitals or health care institutions. Participation in the plan is offered to AHS executives on a prorata schedule beginning with 20 years of service as an employee of AHS and/or another hospital or health care institution controlled by the Seventh-Day Adventist Church and who satisfy certain other qualifying criteria. This supplemental executive retirement plan (SERP) was designed to provide eligible executives with the economic equivalent of an annual income beginning at normal retirement age equal to 60% of the average of the participant's three, five or seven highest years of base salary from AHS active employment inclusive of income from all other Seventh-Day Adventist Church healthcare employer-financed retirement income sources and investment income earned on those contributions through social security normal retirement age as defined in the plan. The number of years included in highest average compensation is determined by the individual's year of entry to the SERP and by the individual's year of entry to the AHS Executive FLEX Benefit Program. Flex Plan Flex Plan/ SERP 457(b) CY CY Employer CY Contrib./ Distributions Contrib. Distributions* Payment ------------------------------------------------------- Kenneth Bacon $ 68,593 $ 43,176 $ 180,499 $ 0 Douglas Peterson $ 9,441 $ 8,725 $ 191,328 $ 0 Ronald Wehtje $ 7,707 $ 35,071 $ 0 $ 0 Karsten Randolph $ 33,995 $ 34,350 $ 0 $ 0 *Including Investment Earnings |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| Jody Gilles | |||
| Family member of current board member | $52,805 | Employee Compensation | 0 |
| Charles Heike | |||
| Family member of current board member | $62,784 | Contractor Compensation | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (14 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part V, Line 1a: | The parent corporation and sole member of Chippewa Valley Hospital and Oakview Care Center, Inc. (the filing organization) is Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is a Florida, not-for-profit corporation that is exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). AHSSHC has established a shared service center to centralize the Accounts Payable (A/P), Payroll, HR, and Materials Management functions for all AHSSHC subsidiary organizations. The facts and circumstances support a position that AHSSHC, as a payor on behalf of its subsidiary organizations in a shared service environment, will have sufficient management and oversight in connection with the subsidiary organizations' payments to meet the standard set forth in Treas. Reg. Section 1.6041-1(e). AHSSHC will not merely be making payments at the direction of its subsidiary organizations. Accordingly, AHSSHC is considered the payor subject to the information reporting requirements of Section 6041. During 2016, the filing organization transitioned its A/P function to AHSSHC. Accordingly, the number entered on line 1a represents the number reported on Box 3 of Form 1096 as filed by the filing organization for 2016. Subsequent to the transition of the A/P function to the AHSSHC shared service center, the filing organization will not enter any amount on Part V, line 1a. As a result of this transition, the filing organization no longer issues Form 1099 returns, rather, all such returns are filed by and under the name and EIN of AHSSHC as the payor subject to the information reporting requirements of Section 6041. |
| Form 990, Part VI, Section A, line 2 | Todd Bechel and Mark Gilles - Family Relationship |
| Form 990, Part VI, Section A, line 6 | Chippewa Valley Hospital and Oakview Care Center, Inc. (the filing organization) has one member. The sole member of the filing organization is Adventist Health System/Sunbelt, Inc. Adventist Health System/Sunbelt, Inc. (AHSSI) is a Florida, not-for-profit corporation that is exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). There are no other classes of membership in the filing organization. |
| Form 990, Part VI, Section A, line 7a | The sole member of the filing organization is AHSSI. The Board of Directors of the filing organization are appointed by the sole member, AHSSI, who has the right to elect, appoint or remove any member of the Board of Directors of the filing organization. |
| Form 990, Part VI, Section A, line 7b | AHSSI, as the sole member of the filing organization, has certain reserved powers as set forth in the Bylaws of the filing organization. These reserved powers include the following: a) to approve and disapprove the executive and/or administrative leadership of the filing organization, and their salaries; b) to adopt, amend, restate, and repeal the Articles of Incorporation or Bylaws of the filing organization; c) to set limits and terms for the borrowing of funds; d) to approve or disapprove major building programs and/or a purchase or sale of personal property or real property equal to or in excess of One Million dollars; e) to approve or disapprove the annual operating and capital budgets of the filing organization; f) to direct the placement of funds and capital of the filing organization; g) to establish general guiding policies; h) to approve or disapprove opening or closing of the facilities or major changes in operation; and i) to establish a process for addressing patient grievances. |
| Form 990, Part VI, Section B, line 11b | The filing organization's current year Form 990 was reviewed by the Board Chairman, Board Finance Committee Chair, CEO and by the CFO prior to its filing with the IRS. The review conducted by the Board Chairman, Board Finance Committee Chair, CEO and the CFO did not include the review of any supporting workpapers that were used in preparation of the current year Form 990, but did include a review of the entire Form 990 and all supporting schedules. |
| Form 990, Part VI, Section B, line 12c | The Conflict of Interest Policy of the filing organization applies to members of its Board of Directors and its principal officers (to be known as Interested Persons). In connection with any actual or possible conflict of interests, any member of the Board of Directors of the filing organization or any principal officer of the filing organization (i.e. Interested Persons) must disclose the existence of any financial interest with the filing organization and must be given the opportunity to disclose all material facts concerning the financial interest/arrangement to the Board of Directors of the filing organization or to any members of a committee with board delegated powers that is considering the proposed transaction or arrangement. Subsequent to any disclosure of any financial interest/arrangement and all material facts, and after any discussion with the relevant Board member or principal officer, the remaining members of the Board of Directors or committee with board delegated powers shall discuss, analyze, and vote upon the potential financial interest/arrangement to determine if a conflict of interest exists. According to the filing organization's Conflict of Interest Policy, an Interested Person may make a presentation to the Board of Directors (or committee with board delegated powers), but after such presentation, shall leave the meeting during the discussion of, and the vote on, the transaction or arrangement that results in a conflict of interest. Each Interested Person, as defined under the filing organization's Conflict of Interest Policy, shall annually sign a statement which affirms that such person has received a copy of the Conflict of Interests policy, has read and understands the policy, has agreed to comply with the policy, and understands that the filing organization is a charitable organization that must primarily engage in activities which accomplish one or more of its exempt purposes. the filing organization's Conflict of Interest Policy also requires that periodic reviews shall be conducted to ensure that the filing organization operates in a manner consistent with its charitable purposes. |
| Form 990, Part VI, Section B, line 15 | The filing organization's CEO, other officers and certain key employees are not compensated by the filing organization. Such individuals are compensated by the related top-tier parent organization of the filing organization. Please see the discussion concerning the process followed by the related top-tier parent organization in determining executive compensation in our response to Schedule J, Line 3. |
| Form 990, Part VI, Section C, line 19 | The filing organization is a part of the system of healthcare organizations known as Adventist Health System (AHS). The audited consolidated financial statements of AHS and of the AHS "Obligated Group" are filed annually with the Municipal Securities Rulemaking Board (MSRB). The "Obligated Group" is a group of AHSSHC subsidiaries that are jointly and severally liable under a Master Trust Indenture that secures debt primarily issued on a tax-exempt basis. Unaudited quarterly financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) are also filed with MSRB for AHS on a consolidated basis and for the grouping of AHS subsidiaries comprising the "Obligated Group". The filing organization does not generally make its governing documents or conflict of interest policy available to the public. |
| Part VII, Section A | For those Board of Director members and officer(s) who devote less than full-time to the filing organization (based upon the average number of hours per week shown in column (B) on page 7 of the return) the compensation amounts shown in columns (E) and (F) on page 7 were provided in conjunction with that person's responsibilities and roles in serving in an executive leadership position within Adventist Health System. |
| Part VIII, Lines 7b and 7c: | The amounts shown in Part VIII Lines 7b and 7c of the Form 990 represent an allocated share of capital gain/(loss) from a system wide, corporate administered, investment program. |
| Form 990, Part IX, line 11g | Payments to Healthcare Professional: Program service expenses 1,042,227. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,042,227. Professional Fees : Program service expenses 751,666. Management and general expenses 0. Fundraising expenses 0. Total expenses 751,666. Purchased Medical Services : Program service expenses 78,442. Management and general expenses 0. Fundraising expenses 0. Total expenses 78,442. Environmental Services: Program service expenses 729. Management and general expenses 0. Fundraising expenses 0. Total expenses 729. Transcription : Program service expenses 374. Management and general expenses 0. Fundraising expenses 0. Total expenses 374. Miscellaneous Purchased Services : Program service expenses 997,896. Management and general expenses 0. Fundraising expenses 0. Total expenses 997,896. AHS Management Fees : Program service expenses 0. Management and general expenses 132,401. Fundraising expenses 0. Total expenses 132,401. Billing & Collection Services : Program service expenses 0. Management and general expenses 43,507. Fundraising expenses 0. Total expenses 43,507. AHS Shared Service Fee : Program service expenses 0. Management and general expenses 54,334. Fundraising expenses 0. Total expenses 54,334. |
| Form 990, Part XI, line 9: | Allocations from tax-exempt parent with respect to debt 2,898. Transfer to tax-exempt parent -79,161. |
| Part X, Line 2 | The amounts shown on line 2 of Part X of this return include the filing organization's interest in a central investment pool maintained by Adventist Health System Sunbelt Healthcare Corporation, the filing organization's top-tier parent. The investments in the central investment pool are recorded at market value. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (101 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Adventist Bolingbrook Hospital | |||||||||||
| 500 Remington Blvd | Bolingbrook | IL | 60440 | 651219504 | Operation of Hospital & Related Services | IL | 501(c)(3) | Line 3 | Adventist Midwest Health | Yes (1) | |
| Adventist Care Centers - Courtland Inc | |||||||||||
| 730 Courtland Street | Orlando | FL | 32804 | 205774723 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Adventist GlenOaks Hospital | |||||||||||
| 701 Winthrop Avenue | Glendale Heights | IL | 60139 | 363208390 | Operation of Hospital & Related Services | IL | 501(c)(3) | Line 3 | Adventist Midwest Health | Yes (1) | |
| Adventist Hlth Mid-America Inc | |||||||||||
| 9100 W 74th Street | Shawnee Mission | KS | 66204 | 521347407 | Support of Affiliated Hospital | KS | 501(c)(3) | Line 12c, III-FI | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Adventist Hlth Partners Inc | |||||||||||
| 3040 Salt Creek Lane | Arlington Heights | IL | 60005 | 364138353 | Operation of Physician Practices & Medical Services | IL | 501(c)(3) | Line 3 | AHS Midwest Management Inc | Yes (1) | |
| Adventist Hlth System Sunbelt Hlthcare Corp | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 592170012 | Management Services | FL | 501(c)(3) | Line 12a, I | 0 | N/A | |
| Adventist Hlth System Georgia Inc | |||||||||||
| 1035 Red Bud Road | Calhoun | GA | 30701 | 581425000 | Operation of Hospital & Related Services | GA | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Adventist Hlth SystemSunbelt Inc | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 591479658 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Adventist Hlth SystemTexas Inc | |||||||||||
| 11801 S Freeway | Burleson | TX | 76028 | 742578952 | Leasing Personnel to Affiliated Hospital | TX | 501(c)(3) | Line 12c, III-FI | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Adventist Midwest Health | |||||||||||
| 120 North Oak Street | Hinsdale | IL | 60521 | 362276984 | Operation of Hospital & Related Services | IL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Adventist University of Health Sciences Inc (630 Year End) | |||||||||||
| 671 Lake Winyah Drive | Orlando | FL | 32803 | 593069793 | Education/Operation of School | FL | 501(c)(3) | Line 2 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| AHP Specialty Care NFP | |||||||||||
| 3040 Salt Creek Lane | Arlington Heights | IL | 60005 | 811105774 | Operation of Physician Practices & Medical Services | IL | 501(c)(3) | Line 3 | AHS Midwest Management Inc | Yes (1) | |
| AHS Midwest Management Inc | |||||||||||
| 1000 Remington Blvd Ste 200 | Bolingbrook | IL | 60440 | 363354567 | Operation of Physician Practice Mgmt | IL | 501(c)(3) | Line 12a, I | Adventist Midwest Health | Yes (1) | |
| AHSCentral Texas Inc | |||||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 742621825 | Provide Office Space - Medical Professionals | TX | 501(c)(3) | Line 12c, III-FI | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Apopka Hlth Care Properties Inc | |||||||||||
| 305 E Oak Street | Apopka | FL | 32703 | 510605694 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Battle Creek Adventist Hospital | |||||||||||
| 1000 Remington Blvd Ste 200 | Bolingbrook | IL | 60440 | 381359189 | Inactive | MI | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Bolingbrook Hospital Foundation | |||||||||||
| 1000 Remington Blvd N Entrance 2nd | Bolingbrook | IL | 60440 | 900494445 | Fund-raising for Tax-exempt hospital | IL | 501(c)(3) | Line 7 | Midwest Hlth Foundation | 0 | |
| Bradford Heights Hlth & Rehab Center Inc | |||||||||||
| 950 Highpoint Drive | Hopkinsville | KY | 42240 | 205782342 | Operation of Home for the Aged/Hlthcare Delivery | KY | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Burleson Nursing & Rehab Center Inc | |||||||||||
| 301 Huguley Blvd | Burleson | TX | 76028 | 205782243 | Operation of Home for the Aged/Hlthcare Delivery | TX | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Caldwell Hlth Care Properties Inc | |||||||||||
| 1333 West Main | Princeton | KY | 42445 | 510605680 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Central Texas Hlthcare Collaborative | |||||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 453739929 | Support Operation of Hospital | TX | 501(c)(3) | Line 12a, I | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Chickasaw Hlth Care Properties Inc | |||||||||||
| 250 S Chickasaw Trail | Orlando | FL | 32825 | 510605681 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Chippewa Valley Hospital & Oakview Care Center Inc | |||||||||||
| 1220 Third Avenue West | Durand | WI | 54736 | 391365168 | Operation of Hospital & Related Services | WI | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Courtland Hlth Care Properties Inc | |||||||||||
| 730 Courtland Street | Orlando | FL | 32804 | 510605682 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Creekwood Place Nursing & Rehab Center Inc | |||||||||||
| 107 Boyles Drive | Russellville | KY | 42276 | 205782260 | Operation of Home for the Aged/Hlthcare Delivery | KY | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Dairy Road Hlth Care Properties Inc | |||||||||||
| 7350 Dairy Road | Zephyrhills | FL | 33540 | 510605684 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| East Orlando Hlth & Rehab Center Inc | |||||||||||
| 250 S Chickasaw Trail | Orlando | FL | 32825 | 205774748 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Emory-Adventist Inc | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 582171011 | Inactive | GA | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Fletcher Hospital Inc | |||||||||||
| 100 Hospital Drive | Hendersonville | NC | 28792 | 560543246 | Operation of Hospital & Related Svcs | NC | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| FLNC Inc | |||||||||||
| 3355 E Semoran Blvd | Apopka | FL | 32703 | 205774761 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Florida Hospital Healthcare Partners Inc | |||||||||||
| 770 West Granada Blvd 101 | Ormond Beach | FL | 32174 | 462354804 | Operation of Physician Practices & Medical Services | FL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Florida Hospital Medical Group Inc | |||||||||||
| 2600 Westhall Ln 4th Floor | Maitland | FL | 32751 | 593214635 | Operation of Physician Practices & Medical Services | FL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Florida Hospital Physician Group Inc | |||||||||||
| 12470 Telecom Dr 100 | Tampa | FL | 33637 | 462021581 | Operation of Physician Practices & Medical Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Florida Hospital Waterman Inc | |||||||||||
| 1000 Waterman Way | Tavares | FL | 32778 | 593140669 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Florida Hospital Zephyrhills Inc | |||||||||||
| 7050 Gall Blvd | Zephyrhills | FL | 33541 | 592108057 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Foundation for Shawnee Mission Medical Center Inc | |||||||||||
| 9100 W 74th Street | Shawnee Mission | KS | 66204 | 480868859 | Fund-raising for Tax-exempt hospital | KS | 501(c)(3) | Line 7 | Shawnee Mission Medical Center Inc | Yes (1) | |
| Fountain Inn Nursing & Rehab Center Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 472180518 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| GlenOaks Hospital Foundation | |||||||||||
| 701 Winthrop Avenue | Glendale Heights | IL | 60139 | 363926044 | Fund-raising for Tax-exempt hospital | IL | 501(c)(3) | Line 7 | Midwest Hlth Foundation | 0 | |
| Helen Ellis Memorial Hospital Auxiliary Inc | |||||||||||
| 1395 S Pinellas Ave | Tarpon Springs | FL | 34689 | 592106043 | Fund-raising for Tax-exempt hospital/foundation | FL | 501(c)(3) | Line 12c, III-FI | 0 | ||
| Helen Ellis Memorial Hospital Foundation Inc | |||||||||||
| 1395 S Pinellas Ave | Tarpon Springs | FL | 34689 | 593690149 | Fund-raising for Tax-exempt hospital | FL | 501(c)(3) | Line 7 | Tarpon Springs Hospital Foundation Inc | 0 | |
| Hinsdale Hospital Foundation | |||||||||||
| 7 Salt Creek Lane Suite 203 | Hinsdale | IL | 60521 | 521466387 | Fund-raising for Tax-exempt hospital | IL | 501(c)(3) | Line 7 | Midwest Hlth Foundation | 0 | |
| Hospice of the Comforter Inc | |||||||||||
| 480 W Central Parkway | Altamonte Springs | FL | 32714 | 592935928 | Operation of Hospice | FL | 501(c)(3) | Line 10 | The Comforter Health Care Group Inc | Yes (1) | |
| Hospice of the Comforter Foundation Inc | |||||||||||
| 480 W Central Parkway | Altamonte Springs | FL | 32714 | 271858033 | Fund Raising for Affiliated Tax-Exempt Hospice | FL | 501(c)(3) | Line 7 | The Comforter Health Care Group Inc | Yes (1) | |
| In-Motion Rehab Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 208023411 | Therapy services to tax exempt nursing homes | KS | 501(c)(3) | Line 12b, II | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| La Grange Memorial Hospital Foundation | |||||||||||
| 5101 S Willow Springs Rd | La Grange | IL | 60525 | 300247776 | Fund-raising for Tax-exempt hospital | IL | 501(c)(3) | Line 7 | Midwest Hlth Foundation | 0 | |
| Lake County Health Care Properties Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 813923985 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Memorial Hlth Systems Foundation Inc | |||||||||||
| 770 West Granada Blvd | Ormond Beach | FL | 32174 | 311771522 | Fund-raising for Tax-exempt hospital | FL | 501(c)(3) | Line 7 | 0 | ||
| Memorial Hlth Systems Inc | |||||||||||
| 301 Memorial Medical Parkway | Daytona Beach | FL | 32117 | 590973502 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Memorial Hospital - West Volusia Inc | |||||||||||
| 701 West Plymouth Avenue | Deland | FL | 32720 | 593256803 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Memorial Hlth Systems Inc | Yes (1) | |
| Memorial Hospital Flagler Inc | |||||||||||
| 60 Memorial Medical Parkway | Palm Coast | FL | 32164 | 592951990 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Memorial Hlth Systems Inc | Yes (1) | |
| Memorial Hospital Inc | |||||||||||
| 210 Marie Langdon Drive | Manchester | KY | 40962 | 610594620 | Operation of Hospital & Related Services | KY | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Merriam Hlth Care Properties Inc | |||||||||||
| 9700 West 62nd Street | Merriam | KS | 66203 | 364595806 | Lease to Related Organization | KS | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Metroplex Adventist Hospital Inc | |||||||||||
| 2201 S Clear Creek Road | Killeen | TX | 76549 | 742225672 | Operation of Hospital & Related Services | TX | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Metroplex Clinic Physicians Inc | |||||||||||
| 2201 S Clear Creek Road | Killeen | TX | 76549 | 113762050 | Physician Hlthcare services to the community | TX | 501(c)(3) | Line 3 | Metroplex Adventist Hospital Inc | Yes (1) | |
| Midwest Hlth Foundation | |||||||||||
| 120 North Oak Street | Hinsdale | IL | 60521 | 352230515 | Support of subsidiary Foundations | IL | 501(c)(3) | Line 12b, II | 0 | N/A | |
| Mills Hlth & Rehab Center Inc | |||||||||||
| 500 Beck Lane | Mayfield | KY | 42066 | 205782320 | Operation of Home for the Aged/Hlthcare Delivery | KY | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Mission Strategies of Georgia Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 900866024 | Provision of support to the nursing home division | GA | 501(c)(3) | Line 12b, II | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Missouri Adventist Hlth Inc | |||||||||||
| 9100 W 74th Street | Shawnee Mission | KS | 66204 | 431224729 | Support Hlth Care Services | MO | 501(c)(3) | Line 12d, III-O | Adventist Hlth Mid-America Inc | Yes (1) | |
| Ormond Beach Memorial Hospital Auxiliary Inc | |||||||||||
| 301 Memorial Medical Parkway | Daytona Beach | FL | 32117 | 591721962 | Volunteer support services | FL | 501(c)(3) | Line 12c, III-FI | 0 | ||
| Osceola Health Care Properties Inc (620-123116) | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 813165729 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Overland Park Nursing & Rehab Center Inc | |||||||||||
| 6501 West 75th Street | Overland Park | KS | 66204 | 205774821 | Operation of Home for the Aged/Hlthcare Delivery | KS | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Paragon Hlth Care Properties Inc | |||||||||||
| 950 Highpoint Drive | Hopkinsville | KY | 42240 | 510605686 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Pasco-Pinellas Hillsborough Community Hlth System Inc | |||||||||||
| 2600 Bruce B Downs Blvd | Wesley Chapel | FL | 33544 | 208488713 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Portercare Adventist Hlth System (630 Year End) | |||||||||||
| 9100 E Mineral Circle | Centennial | CO | 80112 | 840438224 | Operation of Hospital & Related Services | CO | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Princeton Hlth & Rehab Center Inc | |||||||||||
| 1333 West Main | Princeton | KY | 42445 | 205782272 | Operation of Home for the Aged/Hlthcare Delivery | KY | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Princeton Professional Services Inc | |||||||||||
| 601 E Rollins Street | Orlando | FL | 32803 | 591191045 | Provision of Hlthcare Services | FL | 501(c)(3) | Line 10 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Quality Circle for Hlthcare Inc | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 263789368 | Hlthcare Quality Services | FL | 501(c)(3) | Line 12a, I | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Resource Personnel Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 208040875 | Provide administrative support to tax exempt nursing homes | FL | 501(c)(3) | Line 12b, II | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Rocky Mountain Adventist Hlthcare Foundation (630 Year End) | |||||||||||
| 7995 E Prentice Ave 204 | Greenwood Village | CO | 80111 | 840745018 | Fund-raising for Tax-exempt hospital | CO | 501(c)(3) | Line 7 | 0 | ||
| Rollins Brook Community Care Corp | |||||||||||
| 2201 S Clear Creek Road | Killeen | TX | 76549 | 461656773 | Support Operation of Hospital | TX | 501(c)(3) | Line 12a, I | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Russellville Hlth Care Properties Inc | |||||||||||
| 683 East Third Street | Russellville | KY | 42276 | 510605691 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| San Marcos Hlth Care Properties Inc | |||||||||||
| 1900 Medical Parkway | San Marcos | TX | 78666 | 510605693 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| San Marcos Nursing & Rehab Center Inc | |||||||||||
| 1900 Medical Parkway | San Marcos | TX | 78666 | 205782224 | Operation of Home for the Aged/Hlthcare Delivery | TX | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Shawnee Mission Hlth Care Inc | |||||||||||
| 6501 West 75th Street | Overland Park | KS | 66204 | 480952508 | Lease to Related Organization | KS | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Shawnee Mission Hlth Care Properties Inc(98-123116) | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 813914908 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Shawnee Mission Medical Center Inc | |||||||||||
| 9100 W 74th Street | Shawnee Mission | KS | 66204 | 480637331 | Operation of Hospital & Related Services | KS | 501(c)(3) | Line 3 | Adventist Hlth Mid-America Inc | Yes (1) | |
| South Central Inc | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 593689740 | Management Support | GA | 501(c)(3) | Line 12c, III-FI | 0 | N/A | |
| South Pasco Hlth Care Properties Inc | |||||||||||
| 38250 A Avenue | Zephyrhills | FL | 33542 | 510605679 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Southeast Volusia Healthcare Corp | |||||||||||
| 401 Palmetto Street | New Smyrna Beach | FL | 32168 | 473793197 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Southwest Volusia Hlth Services Inc | |||||||||||
| 1055 Saxon Blvd | Orange City | FL | 32763 | 593281591 | Medical Office Building for Hospital | FL | 501(c)(3) | Line 12a, I | Southwest Volusia Hlthcare Corp | Yes (1) | |
| Southwest Volusia Hlthcare Corp | |||||||||||
| 1055 Saxon Blvd | Orange City | FL | 32763 | 593149293 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Specialty Physicians of Central Texas Inc | |||||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 208814408 | Physician Hlthcare services to the community | TX | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Spring View Hlth & Rehab Center Inc | |||||||||||
| 718 Goodwin Lane | Leitchfield | KY | 42754 | 205782288 | Operation of Home for the Aged/Hlthcare Delivery | KY | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Sunbelt Hlth & Rehab Center - Apopka Inc | |||||||||||
| 305 East Oak Street | Apopka | FL | 32703 | 205774856 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Sunbelt Hlth Care Centers Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 581473135 | Management Services | TN | 501(c)(3) | Line 12b, II | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| SunSystem Development Corp | |||||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 592219301 | Fund Raising for Affiliated Tax-Exempt Hospitals | FL | 501(c)(3) | Line 7 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| Takoma Regional Hospital Inc (630 Year End)(7115-123116) | |||||||||||
| 401 Takoma Ave | Greeneville | TN | 37743 | 510603966 | Operation of Hospital & Related Services | TN | 501(c)(3) | Line 3 | Adventist Hlth SystemSunbelt Inc | Yes (1) | |
| Takoma Regional Hospital Foundation Inc | |||||||||||
| 401 Takoma Ave | Greeneville | TN | 37743 | 471334302 | Fund Raising for Affiliated Tax-Exempt Hospital | TN | 501(c)(3) | Line 7 | Takoma Regional Hospital Inc | Yes (1) | |
| Tarpon Springs Hospital Foundation Inc | |||||||||||
| 1395 S Pinellas Ave | Tarpon Springs | FL | 34689 | 590898901 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | University Community Hospital Inc | Yes (1) | |
| Tarrant County Hlth Care Properties Inc | |||||||||||
| 301 Huguley Blvd | Burleson | TX | 76028 | 510605677 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Taylor Creek Hlth Care Properties Inc | |||||||||||
| 718 Goodwin Lane | Leitchfield | KY | 42754 | 510605678 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| The Comforter Health Care Group Inc | |||||||||||
| 605 Montgomery Road | Altamonte Springs | FL | 32714 | 271857940 | Lease to Related Organization | FL | 501(c)(3) | Line 12c, III-FI | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| The Volunteer Auxiliary of Florida Hospital - Flagler Inc | |||||||||||
| 60 Memorial Medical Parkway | Palm Coast | FL | 32164 | 592486582 | Volunteer support services | FL | 501(c)(3) | Line 12c, III-FI | 0 | ||
| Tri-County Nursing and Rehab Center Inc | |||||||||||
| 485 North Keller Road 250 | Maitland | FL | 32751 | 472219363 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Trinity Nursing & Rehab Center Inc | |||||||||||
| 9700 West 62nd Street | Merriam | KS | 66203 | 205774890 | Operation of Home for the Aged/Hlthcare Delivery | KS | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| University Community Hospital Foundation Inc | |||||||||||
| 3100 E Fletcher Ave | Tampa | FL | 33613 | 592554889 | Fund-raising for Tax-exempt hospital | FL | 501(c)(3) | Line 12a, I | 0 | ||
| University Community Hospital Specialty Care Inc | |||||||||||
| 3100 E Fletcher Ave | Tampa | FL | 33613 | 593231322 | Inactive | FL | 501(c)(3) | Line 12a, I | University Community Hospital Inc | Yes (1) | |
| University Community Hospital Inc | |||||||||||
| 3100 E Fletcher Ave | Tampa | FL | 33613 | 591113901 | Operation of Hospital & Related Services | FL | 501(c)(3) | Line 3 | Adventist Hlth System Sunbelt Hlthcare Corp | Yes (1) | |
| West Kentucky Hlth Care Properties Inc | |||||||||||
| 500 Beck Lane | Mayfield | KY | 42066 | 510605676 | Lease to Related Organization | GA | 501(c)(3) | Line 12c, III-FI | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Zephyr Haven Hlth & Rehab Center Inc | |||||||||||
| 38250 A Avenue | Zephyrhills | FL | 33542 | 205774930 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
| Zephyrhills Hlth & Rehab Center Inc | |||||||||||
| 7350 Dairy Road | Zephyrhills | FL | 33540 | 205774967 | Operation of Home for the Aged/Hlthcare Delivery | FL | 501(c)(3) | Line 10 | Sunbelt Hlth Care Centers Inc | Yes (1) | |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp (8 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|
| Clear Creek MOB Ltd | |||||||
| 2201 S Clear Creek Rd | Killeen | TX | 76549 | 742609195 | Real Estate | TX | N/A |
| Endoscopy Center at Porter LLC (11-32916) | |||||||
| 1001 South Park Drive | Littleton | CO | 80120 | 205855038 | Medical Services | CO | N/A |
| Florida Hospital DMERT LLC | |||||||
| 500 Winderley Place Ste 324 | Maitland | FL | 32751 | 202392253 | Medical Equipment | FL | N/A |
| Florida Hospital Home Infusion LLP | |||||||
| 500 Winderley Place Ste 324 | Maitland | FL | 32751 | 593142824 | Home Infusion Services | FL | N/A |
| Functional Neurosurgical Ambulatory Surgery Center LLC | |||||||
| 777 S Williams St | Denver | CO | 80209 | 464426708 | Surgery Center | CO | N/A |
| PAHSLarkin Ventures LLC | |||||||
| 9100 E Mineral Cir | Centennial | CO | 80112 | 474211060 | Medical Services | CO | N/A |
| PAHSUSP Surgery Centers LLC | |||||||
| 15305 Dallas Pkwy Ste 1600 LB 28 | Addison | TX | 75010 | 263057950 | Medical Services | CO | N/A |
| San Marcos MRI LP | |||||||
| 1330 Wonder World Dr Ste 202 | San Marcos | TX | 78666 | 770597972 | Imaging & Testing | TX | N/A |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (20 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|
| Altamonte Medical Plaza Condominium Association Inc | |||||||||
| 601 East Rollins Street | Orlando | FL | 32803 | 592855792 | Condo Association | FL | N/A | C | Yes (1) |
| Apopka Medical Plaza Condominium Association Inc | |||||||||
| 601 East Rollins Street | Orlando | FL | 32803 | 593000857 | Condo Association | FL | N/A | C | Yes (1) |
| CC MOB Inc | |||||||||
| 2201 S Clear Creek Road | Killeen | TX | 76549 | 742616875 | Real Estate Rental | TX | N/A | C | Yes (1) |
| Central Texas Medical Associates | |||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 742729873 | Inactive | TX | N/A | C | Yes (1) |
| Central Texas Providers Network | |||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 742827652 | Physician Hospital Org. | TX | N/A | C | Yes (1) |
| Florida Hospital Flagler Medical Offices Association Inc | |||||||||
| 60 Memorial Medical Parkway | Palm Coast | FL | 32164 | 262158309 | Condo Association | FL | N/A | C | Yes (1) |
| Florida Hosp Hlth Village Property Owner's Assoc Inc | |||||||||
| 550 E Rollins Street 7th Floor | Orlando | FL | 32803 | 821748255 | Condo Association | FL | N/A | C | Yes (1) |
| Florida Hospital Healthcare System Inc | |||||||||
| 101 Southhall Lane Ste 150 | Maitland | FL | 32751 | 593215680 | PHSO | FL | N/A | C | Yes (1) |
| Florida Medical Plaza Condo Association Inc | |||||||||
| 601 East Rollins Street | Orlando | FL | 32803 | 592855791 | Condo Association | FL | N/A | C | Yes (1) |
| Florida Memorial Health Network Inc | |||||||||
| 770 W Granada Blvd Ste 317 | Ormond Beach | FL | 32174 | 593403558 | Physician Hospital Org. | FL | N/A | C | Yes (1) |
| Kissimmee Multispecialty Clinic Condominium Association Inc | |||||||||
| 201 Hilda Street Suite 30 | Kissimmee | FL | 34741 | 593539564 | Condo Association | FL | N/A | C | Yes (1) |
| LN Health Partners Inc (815-123116) | |||||||||
| 550 E Rollins Street 6th Floor | Orlando | FL | 32803 | 813556903 | Inactive | FL | N/A | C | Yes (1) |
| Midwest Management Services Inc | |||||||||
| 9100 West 74th Street | Shawnee Mission | KS | 66204 | 480901551 | Inactive | KS | N/A | C | Yes (1) |
| North American Health Services Inc & Sub | |||||||||
| 900 Hope Way | Altamonte Springs | FL | 32714 | 621041820 | Lessor/Holding Co. | TN | N/A | C | Yes (1) |
| Ormond Prof Associates Condo Assoc'n Inc (430 year end) | |||||||||
| 770 W Granada Blvd Ste 101 | Ormond Beach | FL | 32174 | 592694434 | Condo Association | FL | N/A | C | Yes (1) |
| Park Ridge Property Owner's Association Inc | |||||||||
| 1 Park Place Naples Road | Fletcher | NC | 28732 | 030380531 | Condo Association | NC | N/A | C | Yes (1) |
| Porter Aff Hlth Svcs Inc dba Diversified Aff Hlth Svcs | |||||||||
| 2525 S Downing Street | Denver | CO | 80210 | 840956175 | Healthcare Services | CO | N/A | C | Yes (1) |
| San Marcos Regional MRI Inc | |||||||||
| 1301 Wonder World Drive | San Marcos | TX | 78666 | 770597968 | Holding Company | TX | N/A | C | Yes (1) |
| The Garden Retirement Community Inc | |||||||||
| 485 North Keller Road Ste 250 | Maitland | FL | 32751 | 593414055 | Real Estate Rental | FL | N/A | C | Yes (1) |
| Winter Park Medical Office Building I Condo Assoc Inc | |||||||||
| 601 East Rollins Street | Orlando | FL | 32803 | 452228478 | Condo Association | FL | N/A | C | Yes (1) |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (6 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| Shawnee Mission Medical Center Inc | ||
| P | $82,092 | cost |
| Adventist Health System Sunbelt Healthcare Corporation | ||
| M | $185,550 | % of Facility's Operating Exp. |
| adventist Health System Sunbelt Healthcare Corporation dba AHS IS | ||
| M | $481,354 | % of Facility's Operating Exp. |
| Adventist Health System Sunbelt Healthcare Corporation | ||
| P | $1,017,990 | Cost |
| adventist Health System Sunbelt Healthcare Corporation | ||
| B | $79,161 | Actual Amount Given |
| Adventist Health System Sunbelt Healthcare Corporation | ||
| M | $53,149 | % of Facility's Operating Exp. |