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ObjectId: 201932979349300113 - Submission: 2019-10-24
TIN: 20-5392766
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 instructions and the latest information.
OMB No. 1545-0047
20
18
Open to Public Inspection
Name of the organization
COMMUNITY PHYSICIANS OF
INDIANA INC
Employer identification number
20-5392766
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)
COMMUNITY HEALTH NETWORK INC
7330 SHADELAND STATION SUITE 200
INDIANAPOLIS
,
IN
46256
35-0983617
HOSPITAL
IN
501C3
3
NA
No
(2)
COMMUNITY HEALTH NETWORK FOUNDATION
7330 SHADELAND STATION SUITE 100
INDIANAPOLIS
,
IN
46256
51-0181688
SUPPORT
IN
501C3
12B
CHNW
Yes
(3)
COMMUNITY HLTH SERVICES OF INDIANA
7330 SHADELAND STATION SUITE 200
INDIANAPOLIS
,
IN
46256
45-4817436
HLTH CARE
IN
501C3
3
CHNW
Yes
(4)
COMMUNITY HOME HEALTH SERVICES INC
9894 EAST 121ST STREET
FISHERS
,
IN
46037
35-0953467
HLTH CARE
IN
501C3
10
CHNW
Yes
(5)
COMM HOSP OF ANDERSON & MADISON CTY
1515 NORTH MADISON AVENUE
ANDERSON
,
IN
46011
35-1069822
HOSPITAL
IN
501C3
3
CHNW
Yes
(6)
COMMUNITY HOSP ANDERSON FDN INC
1515 NORTH MADISON AVENUE
ANDERSON
,
IN
46011
86-1053152
SUPPORT
IN
501C3
12A
CHA
Yes
(7)
COMMUNITY HOSPITAL SOUTH INC
1402 E COUNTY LINE ROAD SOUTH
INDIANAPOLIS
,
IN
46227
35-1088640
HOSPITAL
IN
501C3
3
CHNW
Yes
(8)
COMMUNITY HOWARD REGIONAL HEALTH
3500 S LAFOUNTAIN STREET
KOKOMO
,
IN
46902
35-1865344
HOSPITAL
IN
501C3
3
CHNW
Yes
(9)
COMM HOWARD REGIONAL HEALTH FDN
PO BOX 9011
KOKOMO
,
IN
46904
23-7309596
SUPPORT
IN
501C3
7
NA
No
(10)
COMMUNITY LTC INC
1030 S SCATTERFIELD ROAD
ANDERSON
,
IN
460124235
35-1877441
HLTH CARE
IN
501C3
10
CHA
Yes
(11)
HEALTH INSTITUTE OF INDIANA INC
3660 GUION ROAD
INDIANAPOLIS
,
IN
46222
35-2022402
FITNESS
IN
501C3
10
CHNW
Yes
(12)
INDIANAPOLIS OSTEOPATHIC HOSP INC
3630 GUION ROAD
INDIANAPOLIS
,
IN
46222
35-1094734
HOSPITAL
IN
501C3
3
CHNW
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2018
Page 2
Schedule R (Form 990) 2018
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)
CHNJMH VENTURES LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
46-2356266
DIAG/REHAB
IN
N/A
No
No
(2)
COMMUNITYACCESSCARE IN DIALYSIS
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
47-4634198
DIALYSIS
IN
N/A
No
No
(3)
COMMUNITY ENDOSCOPY CENTER LLC
1601 N MADISON AVENUE SUITE 300
ANDERSON
,
IN
46011
61-1464136
HLTH CARE
IN
N/A
No
No
(4)
COMM HEALTH NETWORK REHAB HOSP LLC
680 S FOURTH STREET
LOUISVILLE
,
KY
40202
45-3414249
REHAB
IN
N/A
No
No
(5)
COMM HLTH NTWRK RHB HOSP SOUTH LLC
680 S FOURTH STREET
LOUISVILLE
,
KY
40202
82-1385366
REHAB
IN
N/A
No
No
(6)
EAST CAMPUS SURGERY CENTER LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
35-2028517
SURGERY
IN
N/A
No
No
(7)
HAMILTON SURGERY CENTER LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
35-2061413
SURGERY
IN
N/A
No
No
(8)
HOWARD COMMUNITY SURGERY CTR LLC
3500 S LAFOUNTAIN STREET
KOKOMO
,
IN
46902
35-2118748
SURGERY
IN
N/A
No
No
(9)
HOWARD REGIONAL SPECIALTY CARE LLC
680 SOUTH FOURTH STREET
LOUISVILLE
,
KY
40202
37-1501021
REHAB
IN
N/A
No
No
(10)
INDIANAPOLIS ENDOSCOPY CENTER LLP
8315 E 56TH STREET
INDIANAPOLIS
,
IN
46216
35-2010874
HLTH CARE
IN
N/A
No
No
(11)
MICHIGAN SURGERY INVESTMENT LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
32-0147008
SURG CTRS
IN
N/A
No
No
(12)
NORTH CAMPUS OFFICE ASSOCIATES LP
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
35-1808625
RNTL PROP
IN
N/A
No
No
(13)
NORTH CAMPUS SURGERY CENTER LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
35-2147088
SURGERY
IN
N/A
No
No
(14)
NORTHPOINT PEDIATRICS LLC
8101 CLEARVISTA PARKWAY SUITE 185
INDIANAPOLIS
,
IN
46256
35-1960566
HLTH CARE
IN
N/A
No
No
(15)
NORTHWEST SURGERY CENTER LLC
6626 E 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
20-8754071
SURGERY
IN
N/A
No
No
(16)
PILLARS HOUSING LP
3500 S LAFOUNTAIN STREET
KOKOMO
,
IN
46902
16-1652671
HOUSING
IN
N/A
No
No
(17)
PRIMARIA HEALTH LLC
9365 COUNSELORS ROW SUITE 210
INDIANAPOLIS
,
IN
46240
47-4728937
CONSULTING
IN
N/A
No
No
(18)
SCP INDIANAPOLIS LLC
7430 SHADELAND AVENUE SUITE 100
INDIANAPOLIS
,
IN
46250
46-0639908
HLTH CARE
IN
N/A
No
No
(19)
SOUTH CAMPUS SURGERY CENTER LLC
1550 EAST COUNTY LINE ROAD
INDIANAPOLIS
,
IN
46227
35-2038072
SURGERY
IN
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)
CHN ASSURANCE COMPANY LTD
PO BOX 1051 GT
GRAND CAYMAN
,
GRAND CAYMAN
CJ
98-0418913
SELF INSUR
CJ
N/A
Yes
(2)
PILLARS COMMUNITY HOUSING INC
3500 S LAFOUNTAIN STREET
KOKOMO
,
IN
46902
16-1652666
HOUSING
IN
N/A
Yes
(3)
VISIONARY ENTERPRISES INC
6626 EAST 75TH STREET SUITE 200
INDIANAPOLIS
,
IN
46250
35-1538433
MGMT SRVS
IN
N/A
Yes
(4)
VEI MICHIGAN INC
940 N MAIN STREET
ANN HARBOR
,
MI
48104
30-0097377
MGMT SRVS
MI
N/A
Yes
(5)
WESTVIEW DELIVERY SYSTEM INC
3630 GUION ROAD
INDIANAPOLIS
,
IN
46222
35-1910292
MGMT SRVS
IN
N/A
C CORP
638,965
103,861
100.000 %
Yes
Schedule R (Form 990) 2018
Page 3
Schedule R (Form 990) 2018
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
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
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
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
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
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)
COMMUNITY HEALTH NETWORK FOUNDATION
C
1,150,534
BOOK VALUE
(2)
COMMUNITY HEALTH NETWORK FOUNDATION
R
949,514
BOOK VALUE
(3)
COMM HOSP OF ANDERSON & MADISON CTY
K
1,413,323
BOOK VALUE
(4)
COMM HOSP OF ANDERSON & MADISON CTY
Q
3,724,930
BOOK VALUE
(5)
COMM HOSP OF ANDERSON & MADISON CTY
S
227,366
BOOK VALUE
(6)
COMMUNITY HOSPITAL SOUTH INC
K
721,464
BOOK VALUE
(7)
COMMUNITY HOSPITAL SOUTH INC
S
722,531
BOOK VALUE
(8)
COMMUNITY HOWARD REGIONAL HEALTH
K
1,135,526
BOOK VALUE
(9)
COMMUNITY HOWARD REGIONAL HEALTH
S
1,209,751
BOOK VALUE
(10)
HEALTH INSTITUTE OF INDIANA INC
K
167,380
BOOK VALUE
(11)
HEALTH INSTITUTE OF INDIANA INC
S
411,864
BOOK VALUE
(12)
NORTH CAMPUS OFFICE ASSOCIATES LP
S
703,865
BOOK VALUE
(13)
PRIMARIA HEALTH LLC
S
58,567
BOOK VALUE
(14)
VISIONARY ENTERPRISES INC
K
3,884,897
BOOK VALUE
(15)
VISIONARY ENTERPRISES INC
S
3,990,055
BOOK VALUE
(16)
WESTVIEW DELIVERY SYSTEM
S
280,187
BOOK VALUE
Schedule R (Form 990) 2018
Page 4
Schedule R (Form 990) 2018
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) 2018
Page 5
Schedule R (Form 990) 2018
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) 2018
Additional Data
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