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ObjectId: 201610479349301481 - Submission: 2016-02-16
TIN: 23-7426300
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
Attach to Form 990.
Information about Schedule R (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
14
Open to Public Inspection
Name of the organization
LEGACY HEALTH
Employer identification number
23-7426300
Part I
Identification of Disregarded Entities
Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Total income
(e)
End-of-year assets
(f)
Direct controlling
entity
(1)
LEGACY HEALTH SYSTEM CPC LLC
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
23-7426300
COMMON PAY COMPANY
OR
N/A
(2)
LEGACY SINGLE DEPOSITORY ENTITY LLC
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
23-7426300
COMMON DEPOSITORY COMPANY
OR
NA
(3)
LEGACY EPIC FOR AFFILIATED PHYSICIANS
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
ELECTRONIC MEDICAL RECORDS FOR PHYSICIANS
OR
-585,601
1,849,891
N/A
Part II
Identification of Related Tax-Exempt Organizations
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))
(f)
Direct controlling
entity
(g)
Section 512(b)(13) controlled entity?
Yes
No
(1)
LEGACY EMANUEL HOSPITAL & HEALTH CENTER
2801 N GANTENBEIN AVE
PORTLAND
,
OR
97227
93-0386823
HOSPITAL
OR
501(C)(3)
3
N/A
Yes
(2)
LEGACY GOOD SAMARITAN HOSPITAL & MEDICAL
1015 NW 22ND AVE
PORTLAND
,
OR
97210
93-0386793
HOSPITAL
OR
501(C)(3)
3
N/A
Yes
(3)
LEGACY MERIDIAN PARK HOSPITAL
19300 SW 65TH AVE
TUALATIN
,
OR
97062
93-0618975
HOSPITAL
OR
501(C)(3)
3
N/A
Yes
(4)
LEGACY MOUNT HOOD MEDICAL CENTER
24800 SE STARK AT
GRESHAM
,
OR
97030
93-0591528
HOSPITAL
OR
501(C)(3)
3
N/A
Yes
(5)
LEGACY SALMON CREEK HOSPITAL
2211 NE 139TH ST
VANCOUVER
,
WA
98686
33-1065485
HOSPITAL
WA
501(C)(3)
3
N/A
Yes
(6)
LEGACY VISITING NURSE ASSOCIATION
815 NE DAVIS ST
PORTLAND
,
OR
97210
93-0848530
HOSPICE
OR
501(C)(3)
9
N/A
Yes
(7)
EMANUEL MEDICAL CENTER FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
93-6095667
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
Yes
(8)
RANDALL CHILDRENS HOSPITAL FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
93-1314469
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
Yes
(9)
GOOD SAMARITAN FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
23-7017276
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
Yes
(10)
MERIDIAN PARK MEDICAL FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
93-0773410
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
Yes
(11)
MT HOOD MEDICAL CENTER FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
93-0794951
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
Yes
(12)
SALMON CREEK HOSPITAL FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
83-0433165
CHARITABLE FOUNDATION
WA
501(C)(3)
7
N/A
Yes
(13)
LEGACY ADVENTIST VENTURE
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
93-1121816
HEALTHCARE
OR
501(C)(3)
9
N/A
No
(14)
LEGACY HEALTH FOUNDATION
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
46-5562403
CHARITABLE FOUNDATION
OR
501(C)(3)
7
N/A
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2014
Page 2
Schedule R (Form 990) 2014
Page
2
Part III
Identification of Related Organizations Taxable as a Partnership
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
(1)
LEGACYUSP SURGERY CENTERS LLC
15305 DALLAS PKWY SUITE 1600 LB 2
ADDISON
,
TX
75001
26-1846866
MGMT SERV
OR
N/A
Related
75,607
11,307,203
No
No
50.100 %
(2)
LIFE FLIGHT NETWORK LLC
22285 YELLOW GATE LANE SUITE 102
AURORA
,
OR
97002
20-5016802
AIR AMBULANCE
OR
LEHHC
Related
3,592,813
4,900,306
No
No
32.000 %
(3)
WALGREENS INFUSION SERV AT LEGACY LLC
104 WILMOT ROAD MS 1435
DEERFIELD
,
IL
60015
20-3161422
INFUSION
OR
LVNA
Related
892,264
1,167,219
No
No
50.000 %
(4)
NORTHWEST HOSPITAL PARTNERSHIP INC
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
93-0973009
INVESTMENT
OR
LGSHMC
INVESTMENT
117,384
No
No
50.000 %
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Percentage
ownership
(i)
Section 512(b)(13) controlled entity?
Yes
No
(1)
MANAGED HEALTHCARE NORTHWEST
1919 NW LOVEJOY ST
PORTLAND
,
OR
97208
93-0914759
MEDICAL
OR
LEGACY MT HOOD MEDICAL CENTER
C
155,043
275,741
75.000 %
No
(2)
LEGACY HEALTH SYSTEM INSURANCE COMPANY
1919 NW LOVEJOY ST
PORTLAND
,
OR
97209
03-0322342
INSURANCE
N/A
C
766
241,310
100.000 %
No
Schedule R (Form 990) 2014
Page 3
Schedule R (Form 990) 2014
Page
3
Part V
Transactions With Related Organizations
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note.
Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1
During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a
Receipt of
(i)
interest,
(ii)
annuities,
(iii)
royalties, or
(iv)
rent from a controlled entity
.....................
1a
Yes
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
d
Loans or loan guarantees to or for related organization(s)
............................
1d
Yes
e
Loans or loan guarantees by related organization(s)
............................
1e
Yes
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
Yes
h
Purchase of assets from related organization(s)
............................
1h
Yes
i
Exchange of assets with related organization(s)
............................
1i
Yes
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
Yes
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
No
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
Yes
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
Yes
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
Yes
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
Yes
r
Other transfer of cash or property to related organization(s)
............................
1r
Yes
s
Other transfer of cash or property from related organization(s)
............................
1s
Yes
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved
(1)
LEGACY EMANUEL HOSPITAL & HEALTH CENTER
a
5,056,756
Fair Value
(2)
LEGACY GOOD SAMARITAN HOSPITAL & MEDICAL
a
77,160
Fair Value
(3)
LEGACY MERIDIAN PARK HOSPITAL
a
743,692
Fair Value
(4)
LEGACY MOUNT HOOD MEDICAL CENTER
a
360,647
Fair Value
(5)
EMANUEL MEDICAL CENTER FOUNDATION
c
167,520
Cash
(6)
EMANUEL MEDICAL CENTER FOUNDATION
l
430,979
Actual Cost
(7)
RANDALL CHILDRENS HOSPITAL FOUNDATION
l
346,318
Actual Cost
(8)
GOOD SAMARITAN FOUNDATION
c
148,877
Cash
(9)
GOOD SAMARITAN FOUNDATION
l
707,105
Actual Cost
(10)
MERIDIAN PARK MEDICAL FOUNDATION
c
31,111
Cash
(11)
MERIDIAN PARK MEDICAL FOUNDATION
l
512,146
Actual Cost
(12)
MT HOOD MEDICAL CENTER FOUNDATION
c
89,750
Cash
(13)
MT HOOD MEDICAL CENTER FOUNDATION
l
54,248
Actual Cost
(14)
SALMON CREEK HOSPITAL FOUNDATION
c
44,641
Cash
(15)
SALMON CREEK HOSPITAL FOUNDATION
l
178,730
Actual Cost
Schedule R (Form 990) 2014
Page 4
Schedule R (Form 990) 2014
Page
4
Part VI
Unrelated Organizations Taxable as a Partnership
Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(e)
Are all partners
section
501(c)(3)
organizations?
(f)
Share of total income
(g)
Share of
end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2014
Page 5
Schedule R (Form 990) 2014
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference
Explanation
Schedule R (Form 990) 2014
Additional Data
Software ID:
14000265
Software Version:
2014v6.0