efile Public Visual Render
ObjectId: 201641339349300939 - Submission: 2016-05-12
TIN: 41-1813221
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
CENTRACARE HEALTH SYSTEM
Employer identification number
41-1813221
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)
CENTRACARE SURGERY CENTER LLC
1406 6TH AVE N
ST CLOUD
,
MN
56303
61-1514974
SURGICAL CENTER
MN
6,076,130
3,072,107
CENTRACARE HEALTH SYSTEM
(2)
CENTRACARE HEALTH - MONTICELLO
1013 HART BLVD
MONTICELLO
,
MN
55362
46-1584944
HEALTHCARE
MN
67,505,362
61,332,794
CENTRACARE HEALTH SYSTEM
(3)
CENTRACARE HEALTH - PAYNESVILLE
200 W200 WEST FIRST STREET
PAYNESVILLE
,
MN
56362
43-3298651
HEALTHCARE
MN
37,312,695
27,450,763
CENTRACARE HEALTH SYSTEM
(4)
CENTRAL MINNESOTA HEALTH NETWORK LLC (FKA CIN LLC)
1406 6TH AVE N
ST CLOUD
,
MN
56303
47-3924684
CLINICAL INEGRATED NETWORK
MN
0
0
CENTRACARE HEALTH SYSTEM
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)
ST CLOUD HOSPITAL
1406 6TH AVE N
ST CLOUD
,
MN
56303
41-0695596
ACUTE/LT CARE
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(2)
CENTRACARE HEALTH-MELROSE
11 NORTH 5TH AVE WEST
MELROSE
,
MN
56352
41-1865315
ACUTE/LT CARE
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(3)
CENTRACARE HEALTH-LONG PRAIRIE
20 SE 9TH STREET
LONG PRAIRIE
,
MN
56347
41-1924645
ACUTE/LT CARE
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(4)
CENTRACARE HEALTH-SAUK CENTRE
425 ELM STREET NORTH
SAUK CENTRE
,
MN
56378
45-2438973
ACUTE/LT CARE
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(5)
CENTRAL MINNESOTA EMERGENCY PHYSICIANS
1406 6TH AVE N
ST CLOUD
,
MN
56303
41-1708142
EMERGENCY PHYSICIANS
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(6)
CENTRACARE CLINIC
1200 6TH AVE NORTH
ST CLOUD
,
MN
56303
41-1806657
MULTI-SPECIALTY
MN
501(C)(3)
LINE 3
CENTRACARE HEALTH SYSTEM
Yes
(7)
CENTRACARE HEALTH FOUNDATION
1406 6TH AVE N
ST CLOUD
,
MN
56303
41-1855173
FUNDRAISING
MN
501(C)(3)
LINE 7
CENTRACARE HEALTH SYSTEM
Yes
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)
MONTICELLO CANCER CENTER
1001 HART BLVD STE 50
MONTICELLO
,
MN
55362
26-1909519
RADIATION & ONCOLOGY SERVICES
MN
CENTRACARE HEALTH SYSTEM - MONTICELLO
RELATED
17,546,053
8,917,590
No
Yes
60.000 %
(2)
NORTH STAR SURGICAL SERVICES LLC
6339 E SPEEDWAY BLVD SUITE 201
TUCSON
,
AZ
85710
20-1585814
LITHOTRIPSY SERVICES
AZ
CENTRACARE HOLDINGS INC
N/A
No
No
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)
CENTRACARE PHARMACY SERVICES
1406 6TH AVE N
ST CLOUD
,
MN
56303
41-1620618
RETAIL PHARMACIES
MN
CENTRACARE HEALTH SYSTEM
C
-623,095
3,958,536
100.000 %
Yes
(2)
CENTRACARE HOLDINGSINC
1406 6TH AVE N
ST CLOUD
,
MN
56303
47-2688595
HOLDING COMPANY
MN
CENTRACARE HEALTH SYSTEM
C
172,363
2,366,124
100.000 %
Yes
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
No
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
No
d
Loans or loan guarantees to or for related organization(s)
............................
1d
Yes
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
No
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
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)
CENTRACARE HEALTH - LONG PRAIRIE
A
132,868
ARMS LENGTH
(2)
CENTRACARE HEALTH - MELROSE
A
53,906
ARMS LENGTH
(3)
CENTRACARE PHARMACY SERVICES INC
A
120,191
ARMS LENGTH
(4)
CENTRACARE CLINIC
A
3,911,803
ARMS LENGTH
(5)
ST CLOUD HOSPITAL
A
17,152
ARMS LENGTH
(6)
CENTRACARE HEALTH - LONG PRAIRIE
D
2,302,148
ARMS LENGTH
(7)
CENTRACARE CLINIC
O
412,324
ARMS LENGTH
(8)
ST CLOUD HOSPITAL
O
771,315
ARMS LENGTH
(9)
CENTRACARE CLINIC
P
4,540,491
ARMS LENGTH
(10)
ST CLOUD HOSPITAL
P
1,519,923
ARMS LENGTH
(11)
CENTRACARE HEALTH - LONG PRAIRIE
Q
386,976
ARMS LENGTH
(12)
CENTRACARE HEALTH - MELROSE
Q
393,644
ARMS LENGTH
(13)
CENTRACARE HEALTH - SAUK CENTRE
Q
403,933
ARMS LENGTH
(14)
CENTRACARE FOUNDATION
Q
2,259,678
ARMS LENGTH
(15)
CENTRACARE CLINIC
Q
7,786,271
ARMS LENGTH
(16)
ST CLOUD HOSPITAL
Q
44,334,848
ARMS LENGTH
(17)
CENTRACARE CLINIC
R
2,279,000
ARMS LENGTH
(18)
CENTRACARE PHARMACY SERVICES INC
R
1,195,007
ARMS LENGTH
(19)
CENTRACARE HEALTH - LONG PRAIRIE
S
704,012
ARMS LENGTH
(20)
CENTRACARE HEALTH - SAUK CENTRE
S
352,179
ARMS LENGTH
(21)
CENTRACARE HEALTH - MELROSE
S
3,592,299
ARMS LENGTH
(22)
ST CLOUD HOSPITAL
S
23,542,600
ARMS LENGTH
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:
Software Version: