efile Public Visual Render
ObjectId: 202231259349301418 - Submission: 2022-05-05
TIN: 26-4515959
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
20
Open to Public Inspection
Name of the organization
HSHS WISCONSIN MEDICAL GROUP INC
Employer identification number
26-4515959
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)
KIARA CLINICAL INTEGRATION NETWORK LLC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
26-1417684
HEALTHCARE
IL
-1,302,922
744,772
HSSI
(2)
PHYSICIAN CLINICAL INTEGRATION NETWORK LLC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1668647
HEALTHCARE
IL
1,689,514
11,919,402
KCIN
(3)
HSHS ACO LLC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
32-0465666
HEALTHCARE & SOCIAL ASSISTANCE
IL
418,615
675,112
KCIN
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)
HOSPITAL SISTERS HEALTH SYSTEM
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1058692
HEALTHCARE
IL
501(c)(3)
Type III-FI
NA
No
(2)
HOSPITAL SISTERS OF ST FRANCIS FOUNDATION
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1186514
HEALTHCARE
IL
501(c)(3)
7
HSHS
Yes
(3)
HOSPITAL SISTERS HEALTHCARE WEST INC
2661 COUNTY HIGHWAY 1
CHIPPEWA FALLS
,
WI
54729
51-0157933
HEALTHCARE
WI
501(c)(3)
Type I
HSSI
Yes
(4)
SACRED HEART HOSPITAL
990 WEST CLAIREMONT AVENUE
EAU CLAIRE
,
WI
54701
39-0807060
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(5)
ST ANTHONY'S HOSPITAL
503 N MAPLE STREET
EFFINGHAM
,
IL
62401
37-0661233
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(6)
ST ELIZABETH'S HOSPITAL
ONE ST ELIZABETHS BLVD
OFALLON
,
IL
62269
37-0663567
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(7)
ST NICHOLAS HOSPITAL
3100 SUPERIOR AVENUE
SHEBOYGAN
,
WI
53081
39-0808480
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(8)
ST JOHN'S HOSPITAL
800 EAST CARPENTER STREET
SPRINGFIELD
,
IL
62769
37-0661238
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(9)
ST JOSEPH'S HOSPITAL
9515 HOLY CROSS LANE
BREESE
,
IL
62230
37-1208459
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(10)
ST JOSEPH'S HOSPITAL
2661 COUNTY HIGHWAY 1
CHIPPEWA FALLS
,
WI
54729
39-0810545
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(11)
ST MARY'S HOSPITAL
1800 E LAKE SHORE DRIVE
DECATUR
,
IL
62521
37-0661244
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(12)
ST MARY'S HOSPITAL MEDICAL CENTER
1762 SHAWANO AVENUE
GREEN BAY
,
WI
54303
39-0818682
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(13)
ST VINCENT HOSPITAL
835 S VAN BUREN
GREEN BAY
,
WI
51301
39-0817529
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(14)
ST JOSEPH'S HOSPITAL
12866 TROXLER AVENUE
HIGHLAND
,
IL
62249
37-0663568
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(15)
ST FRANCIS HOSPITAL
1215 FRANCISCAN DRIVE
LITCHFIELD
,
IL
62056
37-0661236
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(16)
HOSPITAL SISTERS SERVICES INC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1163402
HEALTHCARE
IL
501(c)(3)
Type III-FI
HSHS
Yes
(17)
HSHS MEDICAL GROUP INC
3215 EXECUTIVE PARK DRIVE
SPRINGFIELD
,
IL
62703
26-3956318
HEALTHCARE
IL
501(c)(3)
Type III-FI
HSSI
Yes
(18)
ORANGE CROSS AMBULANCE INC
919 ASHLAND AVENUE
SHEBOYGAN
,
WI
53081
39-1860942
HEALTHCARE
WI
501(c)(3)
10
ST NICHOLAS
Yes
(19)
UNITY LIMITED PARTNERSHIP
2366 OAK RIDGE CIRCLE
DE PERE
,
WI
54115
39-1750729
HEALTHCARE
WI
501(c)(3)
10
HSSI
Yes
(20)
PRAIRIE EDUCATION & RESEARCH COOPERATIVE
317 NORTH 5TH STREET
SPRINGFIELD
,
IL
62701
37-1157915
HEALTHCARE
IL
501(c)(3)
4
HSSI
Yes
(21)
ST CLARE MEMORIAL HOSPITAL
855 S MAIN STREET
OCONTO FALLS
,
WI
54154
39-0848401
HEALTHCARE
WI
501(c)(3)
3
HSSI
Yes
(22)
HSHS HOLY FAMILY HOSPITAL
200 HEALTHCARE DRIVE
GREENVILLE
,
IL
62246
37-0792770
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(23)
UTLAUT MEMORIAL FOUNDATION
200 HEALTHCARE DRIVE
GREENVILLE
,
IL
62246
37-1140166
FUNDRAISING
IL
501(c)(3)
Type II
HSSI
Yes
(24)
HSHS GOOD SHEPHERD HOSPITAL INC
200 SOUTH CEDAR STREET
SHELBYVILLE
,
IL
62565
37-0512290
HEALTHCARE
IL
501(c)(3)
3
HSSI
Yes
(25)
SHELBY MEMORIAL HOSPITAL EMPLOYEE BENEFIT TRUST
200 SOUTH CEDAR STREET
SHELBYVILLE
,
IL
62565
37-1778753
TRUST
IL
501(a)
HSSI
Yes
(26)
SOUTHERN ILLINOIS CARDIOVASCULAR FACILITY INC
ONE ST ELIZABETHS BLVD
OFALLON
,
IL
62269
37-1276333
HEALTHCARE
IL
501(c)(3)
3
ST ELIZABETH'S HOSPITAL
No
(27)
HOSPITAL SISTERS MISSION OUTREACH CORPORATION
4849 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
35-2271729
RECYCLING MEDICAL SUPPLIES
IL
501(c)(3)
HSHS
Yes
(28)
PRAIRIE CARDIOVASCULAR CONSULTANTS LTD
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1071858
HEALTHCARE
IL
501(c)(3)
10
HSSI
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2020
Page 2
Schedule R (Form 990) 2020
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)
CARPENTER STREET HOTEL LLC
525 NORTH SIXTH STREET
SPRINGFIELD
,
IL
62702
36-4128127
HOTEL
IL
LASANTE INC
N/A
0
0 %
(2)
SPRINGFIELD URGENT CARE REAL ESTATE LLC
PO BOX 19456
SPRINGFIELD
,
IL
627949456
03-0413258
RENTAL REAL ESTATE
IL
LASANTE INC
N/A
0
0 %
(3)
PRAIRIE HEART INSTITUTE MANAGEMENT COMPANY LLC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
26-1479945
MEDICAL
IL
HSHS
Related
-6,718
11,192
No
0
Yes
100 %
(4)
SOUTHWEST ILLINOIS HEALTH SERVICES REAL ESTATE LLP
4000 NORTH ILLINOIS STREET
SWANSEA
,
IL
62226
82-3633320
REAL ESTATE
IL
ST ELIZABETH'S
Related
6,286
1,740,006
No
0
No
50 %
(5)
REHABILITATION HOSPITAL OF WESTERN WISCONSIN LLC
900 W Clairemont Avenue
Eau Claire
,
WI
54701
87-1489748
Medical
DE
HSHS
Related
0
50 %
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)
KIARA INC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1163401
HEALTHCARE
IL
HSHS
C Corporation
1,028,635
20,896,784
100 %
Yes
(2)
LASANTE WISCONSIN INC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
39-1572196
HEALTHCARE
IL
KIARA INC
C Corporation
Yes
(3)
LASANTE INC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
37-1163400
HEALTHCARE
IL
KIARA INC
C Corporation
Yes
(4)
PREVEA HEALTH SERVICES INC
2710 EXECUTIVE DRIVE
GREEN BAY
,
WI
54304
39-1839351
HEALTHCARE
WI
HSSI
C Corporation
-86,336
26,085,061
50 %
Yes
(5)
PREVEA CLINIC INC
2710 EXECUTVE DRIVE
GREEN BAY
,
WI
54304
39-1839349
HEALTHCARE
WI
PHSI
C Corporation
Yes
(6)
RENAISSANCE QUALITY INSURANCE LTD
PO BOX 1159
GRAND CAYMAN
KY11102
CJ
98-0669953
INSURANCE
CJ
HSSI
C Corporation
0
170,845,551
100 %
Yes
(7)
OJV INC
4936 LAVERNA ROAD
SPRINGFIELD
,
IL
62707
46-0873384
HEALTHCARE
IL
LASANTE INC
C Corporation
Yes
Schedule R (Form 990) 2020
Page 3
Schedule R (Form 990) 2020
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
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
No
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) 2020
Page 4
Schedule R (Form 990) 2020
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) 2020
Page 5
Schedule R (Form 990) 2020
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
Schedule R, Part VII RELATED ORGANIZATIONS
DUE TO THE INCREASINGLY COMPLEX ORGANIZATION STRUCTURE OF HOSPITAL SISTERS HEALTH SYSTEM AND AFFILIATES, THE FILING ORGANIZATION HAS ELECTED TO REPORT ALL ORGANIZATIONS WITHIN HOSPITAL SISTERS HEALTH SYSTEM AS RELATED, REGARDLESS OF OWNERSHIP INTEREST OR "CONTROL" AS DEFINED BY THE INSTRUCTIONS TO SCHEDULE R. THE INTENT OF THIS REPORTING IS TO PROMOTE TRANSPARENCY AND INCREASE CONSISTENCY ACROSS THE NUMEROUS FORM 990 SUBMISSIONS BY HOSPITAL SISTERS HEALTH SYSTEM AND AFFILIATES.
Schedule R (Form 990) 2020
Additional Data
Software ID:
20011424
Software Version:
2020v4.0