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ObjectId: 201911339349307471 - Submission: 2019-05-13
TIN: 73-0606129
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.
Go to
www.irs.gov/Form990
for the latest information.
OMB No. 1545-0047
20
17
Open to Public Inspection
Name of the organization
Jane Phillips Memorial Medical Center
Employer identification number
73-0606129
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)
ASCENSION HEALTH ALLIANCE
PO BOX 45998
ST LOUIS
,
MO
631455998
45-3358926
NATIONAL HEALTH SYSTEM
MO
501(c)(3)
Type I
NA
No
(2)
ASCENSION HEALTH
PO BOX 45998
ST LOUIS
,
MO
631455998
31-1662309
NATIONAL HEALTH SYSTEM
MO
501(c)(3)
Type I
ASCENSION HEALTH ALLIANCE
No
(3)
ST JOHN HEALTH SYSTEM INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1215174
SYSTEM PARENT
OK
501(c)(3)
Type I
ASCENSION HEALTH
No
(4)
ST JOHN SAPULPA INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-0662663
HEALTH CARE
OK
501(c)(3)
3
ST JOHN HEALTH SYSTEM INC
Yes
(5)
ST JOHN HEALTH SYSTEM FOUNDATION INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1133139
HEALTH CARE
OK
501(c)(3)
7
ST JOHN HEALTH SYSTEM INC
Yes
(6)
ST JOHN MEDICAL CENTER INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-0579286
HEALTH CARE
OK
501(c)(3)
3
ST JOHN HEALTH SYSTEM INC
Yes
(7)
OWASSO MEDICAL FACILITY INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
20-3700131
HEALTH CARE
OK
501(c)(3)
3
ST JOHN HEALTH SYSTEM INC
Yes
(8)
ST JOHN BROKEN ARROW INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
38-3833117
HEALTH CARE
OK
501(c)(3)
3
ST JOHN HEALTH SYSTEM INC
Yes
(9)
ST JOHN AUXILIARY INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-0999759
HEALTH CARE
OK
501(c)(3)
10
ST JOHN HEALTH SYSTEM INC
Yes
(10)
ST JOHN BUILDING CORPORATION
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
61-1659782
REAL ESTATE
OK
501(c)(2)
ST JOHN HEALTH SYSTEM INC
Yes
(11)
JANE PHILLIPS NOWATA HOSPITAL INC
237 SOUTH LOCUST
NOWATA
,
OK
74048
73-1440267
HEALTH CARE
OK
501(c)(3)
3
ST JOHN HEALTH SYSTEM INC
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2017
Page 2
Schedule R (Form 990) 2017
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)
Oklahoma Cancer Specialists Real Estate Company LLC
12697 E 51st St South
TULSA
,
OK
74146
47-3843491
REAL ESTATE HOLDING
OK
NA
N/A
(2)
SJFI LLC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
46-2713285
ACCOUNTABLE CARE ORGANIZATION
OK
NA
N/A
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)
UTICA SERVICES INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1057650
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(2)
REGIONAL MEDICAL LABORATORIES INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1131608
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(3)
PHYSICIAN SUPPORT SERVICES INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1437252
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(4)
OMNI MEDICAL GROUP INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1335536
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(5)
ST JOHN URGENT CARE CLINICS INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
20-4990275
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(6)
ST JOHN ANESTHESIA SERVICES INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
20-3690446
MEDICAL SERVICES
OK
NA
C Corporation
Yes
(7)
ST JOHN PHYSICIANS INC
1923 SOUTH UTICA AVENUE
TULSA
,
OK
74104
73-1321032
MEDICAL SERVICES
OK
NA
C Corporation
Yes
Schedule R (Form 990) 2017
Page 3
Schedule R (Form 990) 2017
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
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
Yes
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
Yes
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
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)
ST JOHN BUILDING CORPORATION
K
280,535
FAIR MARKET VALUE
(2)
ST JOHN MEDICAL CENTER INC
Q
491,093
FAIR MARKET VALUE
(3)
UTICA SERVICES INC
S
2,152,648
FAIR MARKET VALUE
(4)
REGIONAL MEDICAL LABORATORIES INC
J
111,735
FAIR MARKET VALUE
(5)
REGIONAL MEDICAL LABORATORIES INC
L
2,495,512
FAIR MARKET VALUE
(6)
REGIONAL MEDICAL LABORATORIES INC
P
697,263
FAIR MARKET VALUE
(7)
REGIONAL MEDICAL LABORATORIES INC
Q
251,249
FAIR MARKET VALUE
(8)
ST JOHN PHYSICIANS INC
L
3,107,640
FAIR MARKET VALUE
(9)
ST JOHN PHYSICIANS INC
Q
278,235
FAIR MARKET VALUE
(10)
ST JOHN URGENT CARE INC
J
124,584
FAIR MARKET VALUE
(11)
ST JOHN ANESTHESIA INC
L
1,174,267
FAIR MARKET VALUE
(12)
PHYSICAN SUPPORT SERVICES INC
L
2,580,574
FAIR MARKET VALUE
(13)
PHYSICAN SUPPORT SERVICES INC
P
135,927
FAIR MARKET VALUE
(14)
PHYSICAN SUPPORT SERVICES INC
Q
266,933
FAIR MARKET VALUE
(15)
JANE PHILLIPS NOWATA HOSPITAL INC
L
67,348
FAIR MARKET VALUE
Schedule R (Form 990) 2017
Page 4
Schedule R (Form 990) 2017
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) 2017
Page 5
Schedule R (Form 990) 2017
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) 2017
Additional Data
Software ID:
17005876
Software Version:
2017v2.2