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ObjectId: 201633209349301788 - Submission: 2016-11-15
TIN: 52-1532556
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
15
Open to Public Inspection
Name of the organization
ADVENTIST HEALTHCARE INC
Employer identification number
52-1532556
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)
ADVENTIST CANCER CARE LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
26-2515407
OUTPATIENT CANCER CARE
MD
1,855,067
3,801,188
ADVENTIST HEALTHCARE INC
(2)
AHC HOLDINGS 1 LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1532556
HOLDING COMPANY
MD
0
5,400,000
ADVENTIST HEALTHCARE INC
(3)
AHC HOLDINGS 2 LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1532556
HOLDING COMPANY
DE
0
5,570,774
ADVENTIST HEALTHCARE INC
(4)
ONE HEALTH QUALITY ALLIANCE LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1532556
INTEGRATED PHYSICIAN GROUP
MD
0
-1,070,280
ADVENTIST HEALTHCARE INC
(5)
ONE HEALTH QUALITY ACO LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
47-4070973
MEDICARE SHARED SAVINGS PLAN ACCOUNTABLE CARE ORGANIZATION
MD
0
0
ADVENTIST HEALTHCARE INC
(6)
GERMANTOWN OUTPATIENT IMAGING LLC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
20-4395818
OUTPATIENT IMAGING
MD
0
0
ADVENTIST HEALTHCARE INC
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)
ADVENTIST HEALTHCARE URGENT CARE CENTERS INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
46-1577511
CLINIC - EMERGENCY CARE
MD
501(C)(3)
LINE 9
ADVENTIST HEALTHCARE INC
Yes
(2)
ADVENTIST HOME HEALTH SERVICES INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-0986808
HOME CARE SERVICES
MD
501(C)(3)
LINE 9
ADVENTIST HEALTHCARE INC
Yes
(3)
ADVENTIST PHYSICIAN SERVICES INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
20-4600646
PHYSICIAN SERVICES
MD
501(C)(3)
LINE 9
ADVENTIST HEALTHCARE INC
Yes
(4)
ADVENTIST REHABILITATION HOSPITAL OF MARYLAND INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
20-1486678
REHABILITATION HOSPITAL
MD
501(C)(3)
LINE 3
ADVENTIST HEALTHCARE INC
Yes
(5)
ADVENTIST REHABILITATION INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
30-0780513
REHABILITATION SERVICES
MD
501(C)(3)
LINE 9
ADVENTIST REHABILITATION HOSPITAL OF MARYLAND INC
Yes
(6)
HACKETTSTOWN COMMUNITY HOSPITAL INC
651 WILLOW GROVE STREET
HACKETTSTOWN
,
NJ
07840
22-6106281
HOSPITAL
NJ
501(C)(3)
LINE 3
ADVENTIST HEALTHCARE INC
Yes
(7)
HACKETTSTOWN REGIONAL MEDICAL CENTER EMERGENCY SERVICES INC
651 WILLOW GROVE STREET
HACKETTSTOWN
,
NJ
07840
27-0820164
AMBULANCE SERVICE
NJ
501(C)(3)
LINE 11A, I
HACKETTSTOWN COMMUNITY HOSPITAL INC
Yes
(8)
HACKETTSTOWN COMMUNITY HOSPITAL FOUNDATION INC
651 WILLOW GROVE STREET
HACKETTSTOWN
,
NJ
07840
22-2333410
FUNDRAISING
NJ
501(C)(3)
LINE 11A, I
HACKETTSTOWN COMMUNITY HOSPITAL INC
Yes
(9)
MEDICAL CENTER PARTNERS INC
651 WILLOW GROVE STREET
HACKETTSTOWN
,
NJ
07840
45-4789273
PHYSICIAN SERVICES
NJ
501(C)(3)
LINE 11A, I
HACKETTSTOWN COMMUNITY HOSPITAL INC
Yes
(10)
MID-ATLANTIC ADVENTIST HEALTHCARE CORPORATION
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1884153
HOLDING COMPANY
MD
501(C)(3)
LINE 9
N/A
No
(11)
ADVENTIST BEHAVIORAL HEALTH FOUNDATION INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
20-5479860
FUNDRAISING
MD
501(C)(3)
LINE 11A, I
ADVENTIST HEALTHCARE INC
Yes
(12)
REGINALD S LOURIE CENTER FOR INFANTS AND YOUNG CHILDREN INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1255870
BEHAVIORAL CARE
MD
501(C)(3)
LINE 9
ADVENTIST HEALTHCARE INC
Yes
(13)
SHADY GROVE ADVENTIST HOSPITAL FOUNDATION INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1216429
FUNDRAISING
MD
501(C)(3)
LINE 11A, I
N/A
Yes
(14)
WASHINGTON ADVENTIST HOSPITAL FOUNDATION INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1692158
FUNDRAISING
MD
501(C)(3)
LINE 11A, I
ADVENTIST HEALTHCARE INC
Yes
(15)
WASHINGTON ADVENTIST FITNESS CENTER
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
27-4758462
WELLNESS
MD
501(C)(3)
LINE 9
ADVENTIST HEALTHCARE INC
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2015
Page 2
Schedule R (Form 990) 2015
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)
GERMANTOWN OUTPATIENT IMAGING LLC
20410 OBSERVATION DR STE 104
GERMANTOWN
,
MD
20876
20-4395818
OUTPATIENT IMAGING
MD
N/A
RELATED
250,458
No
No
50.000 %
(2)
SHADY GROVE MEDICAL BUILDING LLC
1650 TYSONS BOULEVARD STE 820
MCLEAN
,
VA
22102
27-4599411
MEDICAL OFFICE BUILDING
MD
N/A
RELATED
-3,459
259,381
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)
PREMIER MEDICAL NETWORK INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
52-1952469
JOINT PHYSICIAN CONT
MD
ADVENTIST HEALTHCARE INC
C
400
18,895
50.000 %
No
(2)
CLARKSBURG COMMUNITY HOSPITAL INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
27-2330124
HOLDS PROPERTY FOR FUTURE NON-PROFIT HOSPITAL
MD
ADVENTIST HEALTHCARE INC
C
100.000 %
No
(3)
WASHINGTON ADVENTIST HOSPITAL INC
820 W DIAMOND AVE SUITE 600
GAITHERSBURG
,
MD
208781419
27-2330170
HOLDS PROPERTY FOR FUTURE NON-PROFIT HOSPITAL
MD
ADVENTIST HEALTHCARE INC
C
100.000 %
No
Schedule R (Form 990) 2015
Page 3
Schedule R (Form 990) 2015
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
No
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
No
e
Loans or loan guarantees by related organization(s)
............................
1e
No
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
No
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
No
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
No
o
Sharing of paid employees with related organization(s)
............................
1o
No
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
No
s
Other transfer of cash or property from related organization(s)
............................
1s
No
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)
HACKETTSTOWN COMMUNITY HOSPITAL FOUNDATION INC
B
10,000
COST
(2)
REGINALD S LOURIE CENTER FOR INFANTS AND YOUNG CHILDREN INC
B
5,400
COST
(3)
SHADY GROVE ADVENTIST HOSPITAL FOUNDATION INC
B
16,000
COST
(4)
SHADY GROVE ADVENTIST HOSPITAL FOUNDATION INC
B
161,498
COST
(5)
WASHINGTON ADVENTIST HOSPITAL FOUNDATION INC
B
10,000
COST
(6)
WASHINGTON ADVENTIST HOSPITAL FOUNDATION INC
B
178,854
COST
(7)
ADVENTIST BEHAVIORAL HEALTH FOUNDATION INC
C
5,155
COST
(8)
SHADY GROVE ADVENTIST HOSPITAL FOUNDATION INC
C
385,827
COST
(9)
WASHINGTON ADVENTIST HOSPITAL FOUNDATION INC
C
576,171
COST
(10)
ADVENTIST HOME HEALTH SERVICES INC
L
684,583
COST
(11)
ADVENTIST PHYSICIAN SERVICES INC
L
357,027
COST
(12)
ADVENTIST REHABILITATION HOSPITAL OF MARYLAND INC
L
1,202,706
COST
(13)
HACKETTSTOWN COMMUNITY HOSPITAL INC
L
2,324,773
COST
(14)
REGINALD S LOURIE CENTER FOR INFANTS AND YOUNG CHILDREN INC
L
165,493
COST
(15)
HACKETTSTOWN COMMUNITY HOSPITAL INC
P
1,527,200
COST
(16)
ADVENTIST HOME HEALTH SERVICES INC
Q
624,963
COST
(17)
ADVENTIST REHABILITATION HOSPITAL OF MARYLAND INC
Q
2,206,560
COST
(18)
HACKETTSTOWN COMMUNITY HOSPITAL INC
Q
5,083,842
COST
Schedule R (Form 990) 2015
Page 4
Schedule R (Form 990) 2015
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) 2015
Page 5
Schedule R (Form 990) 2015
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) 2015
Additional Data
Software ID:
Software Version: