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Object ID: 202241339349304409 - Rendered 2024-05-01
TIN: 84-1262971
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
POUDRE VALLEY HEALTH CARE INC
Employer identification number
84-1262971
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)
TIMBERLINE MEDICAL CLINIC
131 STANLEY AVE
ESTES PARK
,
CO
80517
04-3772090
OUTPATIENT
CO
0
-16,785
PVHC INC
(2)
LAKOTA LAKE LLC
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
84-1447761
OUTPATIENT
CO
1,246,590
50,428,322
PVHC INC
(3)
HERON LAKE LLC
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
26-4189163
OUTPATIENT
CO
0
657,338
PVHC INC
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)
MEDICAL CENTER OF THE ROCKIES
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
04-3730045
TERTIARY CARE
CO
501(C)(3)
LINE 3
PVHC INC
Yes
(2)
UCHEALTH NORTHERN COLORADO FOUNDATION
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
74-1894581
BENEFIT HEALTH
CO
501(C)(3)
LINE 7
PVHC INC
Yes
(3)
POUDRE VALLEY MEDICAL GROUP
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
80-0348943
MEDICAL SERVICES
CO
501(C)(3)
LINE 10
PVH INC
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2020
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)
HARMONY SURGERY CENTER
2127 E HARMONY RD 200
FT COLLINS
,
CO
80528
84-1479751
AMBULATORY SURGERY
CO
N/A
RELATED
2,492,367
2,638,212
No
No
50.000 %
(2)
CENTRE AVENUE HEALTH & REHAB FACILITY
947 WORTHINGTON CIRCLE
FT COLLINS
,
CO
80526
84-1560494
NURSING FACILITY
CO
N/A
RELATED
256,136
892,627
No
No
50.000 %
(3)
COLUMBINE POUDRE HOME CARE
947 WORTHINGTON CIRCLE
FT COLLINS
,
CO
80526
84-1529817
NURSING CARE
CO
N/A
RELATED
147,976
660,538
No
No
50.000 %
(4)
GATEWAY MEDICAL SERVICES
2500 E PROSPECT RD
FT COLLINS
,
CO
80525
84-1427970
REAL EST/MED
CO
N/A
UNRELATED
2,069,642
6,970,216
No
No
50.000 %
(5)
HARMONY IMAGING CENTER
1951 WILMINGTON DRIVE
FT COLLINS
,
CO
80528
58-2479187
MEDICAL IMAGING
CO
N/A
RELATED
126,277
1,946,978
No
No
46.000 %
(6)
SURGERY CENTER OF FORT COLLINS
1100 E PROSPECT ROAD
FT COLLINS
,
CO
80525
84-1541559
SURGICAL PROC
CO
N/A
UNRELATED
-2,987
679,431
No
No
26.000 %
(7)
OCR LOVELAND
2500 E PROSPECT RD
FT COLLINS
,
CO
80525
30-1069701
AMBULATORY SURG
CO
N/A
UNRELATED
308,140
3,111,914
No
No
10.000 %
(8)
PVHS-ICM EHW
2315 E HARMONY RD STE 200
FT COLLINS
,
CO
80528
46-3311308
MEDICAL SERVICES
CO
N/A
RELATED
108,414
602,415
No
No
50.000 %
(9)
PEAK SURGICAL MANAGEMENT
2127 E HARMONY RD 200
FT COLLINS
,
CO
80528
26-0899618
SURGICAL MGMT
CO
N/A
UNRELATED
131,320
81,056
No
No
14.290 %
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)
INNOVATION ENTERPRISES
2315 E HARMONY RD STE 200
FORT COLLINS
,
CO
80528
20-2036774
IT CONSULTING
CO
PVHC
C
8,646
1,650,239
100.000 %
Yes
Schedule R (Form 990) 2020
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
Yes
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
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
Yes
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
Yes
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
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)
INNOVATION ENTERPRISES
A
379,896
TRANSACTION TOTAL
(2)
HARMONY SURGERY CENTER
A
976,455
TRANSACTION TOTAL
(3)
CENTRE AVE HEALTH & REHAB LLC
B
300,000
TRANSACTION TOTAL
(4)
UCHEALTH NORTHERN COLORADO FOUNDATION
B
945,197
TRANSACTION TOTAL
(5)
POUDRE VALLEY MEDICAL GROUP
B
37,692,614
TRANSACTION TOTAL
(6)
UCHEALTH NORTHERN COLORADO FOUNDATION
C
362,211
TRANSACTION TOTAL
(7)
POUDRE VALLEY MEDICAL GROUP
J
2,206,632
TRANSACTION TOTAL
(8)
MEDICAL CENTER OF THE ROCKIES
L
10,511,465
TRANSACTION TOTAL
(9)
POUDRE VALLEY MEDICAL GROUP
L
5,808,841
TRANSACTION TOTAL
(10)
POUDRE VALLEY MEDICAL GROUP
M
5,249,558
TRANSACTION TOTAL
(11)
MEDICAL CENTER OF THE ROCKIES
N
2,398,369
TRANSACTION TOTAL
(12)
POUDRE VALLEY MEDICAL GROUP
N
2,084,891
TRANSACTION TOTAL
(13)
HARMONY SURGERY CENTER
Q
629,011
TRANSACTION TOTAL
(14)
HARMONY SURGERY CENTER
S
3,500,000
TRANSACTION TOTAL
(15)
GATEWAY MEDICAL SERVICES
S
2,726,908
TRANSACTION TOTAL
(16)
MEDICAL CENTER OF THE ROCKIES
S
86,529,278
TRANSACTION TOTAL
Schedule R (Form 990) 2020
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
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 (Form 990) 2020
Additional Data
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