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ObjectId: 201731309349300548 - Submission: 2017-05-10
TIN: 45-2537633
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
PHYSICIAN SPECIALISTS OF NORTHERN
LANCASTER COUNTY MEDICAL GROUP
Employer identification number
45-2537633
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
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)
Apple Hill Surgical Center Inc
PO Box 2767
York
,
PA
174052767
22-2842253
Sole GP in limited ptnrshp operating sur
PA
501(c)(3)
9
NA
No
(2)
Gettysburg Hospital
PO Box 2767
York
,
PA
174052767
23-1352220
Health Care Services
PA
501(c)(3)
3
NA
No
(3)
Gettysburg Hospital Foundation
PO Box 2767
York
,
PA
174052767
23-2251358
Fundraising for Gettysburg Hospital
PA
501(c)(3)
11 Type 1
NA
No
(4)
Healthy Community Pharmacy Inc
PO Box 2767
York
,
PA
174052767
20-0519121
Reduced rate prescription drugs to unins
PA
501(c)(3)
11 Type 1
NA
No
(5)
VNA Community Services
PO Box 2767
York
,
PA
174052767
23-2338591
Home personal care services for elderly
PA
501(c)(3)
9
NA
No
(6)
VNA Home Health Services
PO Box 2767
York
,
PA
174052767
23-1352573
Home health and hospice care services
PA
501(c)(3)
9
NA
No
(7)
WellSpan Health
PO Box 2767
York
,
PA
174052767
22-2517863
Integrated Health System
PA
501(c)(3)
11 Type 1
NA
No
(8)
WellSpan Health Care Services
PO Box 2767
York
,
PA
174052767
23-2400237
Health-related activites in the service
PA
501(c)(3)
11 Type 1
NA
No
(9)
WellSpan Medical Group
PO Box 2767
York
,
PA
174052767
23-2730785
Medical and surgical care
PA
501(c)(3)
9
NA
No
(10)
York Health Foundation
PO Box 2767
York
,
PA
174052767
23-3050192
Charitable contributions for WellSpan en
PA
501(c)(3)
11 Type 3
NA
No
(11)
York Hospital
PO Box 2767
York
,
PA
174052767
23-1352222
Community teaching hospital
PA
501(c)(3)
3
NA
No
(12)
WellSpan Specialty Services
PO Box 2767
York
,
PA
174052767
23-2899911
Mgmt. hospice/home health
PA
501(c)(3)
11 Type 1
NA
No
(13)
WellSpan Properties
PO Box 2767
York
,
PA
174052767
22-2842252
Leases facilities to affiliates
PA
501(c)(3)
11 Type 1
NA
No
(14)
Ephrata Community Hospital
PO Box 2767
York
,
PA
174052767
23-1370484
Health care services
PA
501(c)(3)
3
NA
No
(15)
Ephrata Community Health Foundation
PO Box 2767
York
,
PA
174052767
80-0940005
Fundraising for Ephrata Hospital
PA
501(c)(3)
11 Type 1
Ephrata Community Hospital
No
(16)
Northern Lancaster County Medical Group
PO Box 2767
York
,
PA
174052767
20-3033058
Medical and surgical care
PA
501(c)(3)
11 Type II
Ephrata Community Hospital
No
(17)
Good Samaritan Hospital
PO Box 2767
York
,
PA
174052767
23-0794160
Health Care Services
PA
501(c)(3)
3
NA
No
(18)
Wellspan Philhaven
PO Box 2767
York
,
PA
174052767
23-1549922
Health Care Services
PA
501(c)(3)
3
NA
No
(19)
Good Samaritan Health Service Foundation
PO Box 2767
York
,
PA
174052767
23-2356151
Fundraising for Good Samaritan
PA
501(c)(3)
11 Type 1
NA
No
(20)
Good Samaritan Real Estate
PO Box 2767
York
,
PA
174052767
23-2447262
Leases facilities to affiliates
PA
501(c)(2)
NA
No
(21)
Good Samaritan Physician Services
PO Box 2767
York
,
PA
174052767
25-1832359
Medical and Surgical Care
PA
501(c)(3)
9
NA
No
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)
Apple Hill Surgical Center Partners
PO Box 2767
York
,
PA
174052767
23-2489452
Surgical Center
PA
AHSCI
No
No
(2)
Central PA Alliance Laboratories LLC
PO Box 2767
York
,
PA
174052767
23-2910950
Ref. Lab
PA
NA
No
No
(3)
Littlestown Health Care Partners
300 West King Street
Littlestown
,
PA
17340
23-2880464
Lease facility
PA
NA
No
No
(4)
Cherry Tree Cancer Center LLP
PO Box 2767
York
,
PA
174052767
23-2915628
Radiation
PA
NA
No
No
(5)
The Rehab Center
855 Springdale Drive Suite 20
Exton
,
PA
19341
25-1687903
Physical Therapy Rehab
PA
Ephrata Hospital
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)
WellSpan Pharmacy Inc
PO Box 2767
York
,
PA
174052767
23-2374072
Dispense Rx's & prov
PA
WHCS
C corp
No
(2)
WellSpan Reciprocal Risk Retention Group
PO Box 2767
York
,
PA
174052767
20-0048457
Risk Retention Group
PA
N/A
C corp
No
(3)
York Health Plan
PO Box 2767
York
,
PA
174052767
23-2664989
Preferred Provider O
PA
N/A
C corp
No
(4)
WellSpan Provider Network
PO Box 2767
York
,
PA
174052767
23-2907828
Coordinate managed c
PA
N/A
C corp
No
(5)
Apple Hill Condominium Association
PO Box 2767
York
,
PA
174052767
23-2504543
Condo Mgmt Associati
PA
N/A
Homeowners Assoc
No
(6)
North Lanc Co Phys Hosp Alliance
PO Box 2767
York
,
PA
174052767
23-2421885
Coord Phys & Hospital
PA
NA
C Corp
No
(7)
GSH Home Med Care Inc
PO Box 2767
York
,
PA
174052767
23-3028099
Sales/rent of med equip/supplies
PA
GSH Services
C corp
No
(8)
GSH Services Inc
PO BOx 2767
York
,
PA
174052767
23-2353047
Accounting and financial management
PA
GS Health Foundation
C corp
No
(9)
GSH Realty Inc
PO Box 2767
York
,
PA
174052767
25-1832359
Rental non-res. real estate
PA
GSH Services
C corp
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
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
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
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
No
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
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:
15000324
Software Version:
2015v3.0