SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2020
Open to Public Inspection
Name of the organization
CHAMBERSBURG HOSPITAL
 
Employer identification number

23-0465970
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,PA174052767
22-2842253 		Sole GP in limited ptnrshp operating sur PA 501(c)(3) 10 Wellspan Health Care Services
 
 
No
(2)Gettysburg Hospital
PO Box 2767

York,PA174052767
23-1352220 		Health Care Services PA 501(c)(3) 3 Wellspan Health
 
 
No
(3)Gettysburg Hospital Foundation
PO Box 2767

York,PA174052767
23-2251358 		Fundraising for Gettysburg Hospital PA 501(c)(3) 12 Type II Gettysburg Hospital
 
 
No
(4)Healthy Community Pharmacy Inc
PO Box 2767

York,PA174052767
20-0519121 		Reduced rate prescription drugs PA 501(c)(3) 12 Type I Wellspan Health Care Services
 
 
No
(5)VNA Community Services
PO Box 2767

York,PA174052767
23-2338591 		Home personal care services for elderly PA 501(c)(3) 10 Wellspan Specialty Services
 
 
No
(6)VNA Home Health Services
PO Box 2767

York,PA174052767
23-1352573 		Home health services PA 501(c)(3) 10 Wellspan Specialty Services
 
 
No
(7)Wellspan Health
PO Box 2767

York,PA174052767
22-2517863 		Integrated Health System PA 501(c)(3) 12 Type III NA
 
 
No
(8)Wellspan Health Care Services
PO Box 2767

York,PA174052767
23-2400237 		Health-related activities in the service PA 501(c)(3) 12 Type II Wellspan Health
 
 
No
(9)Wellspan Medical Group
PO Box 2767

York,PA174052767
23-2730785 		Medical and surgical care PA 501(c)(3) 10 Wellspan Health
 
 
No
(10)York Health Foundation
PO Box 2767

York,PA174052767
23-3050192 		Charitable contributions for Wellspan PA 501(c)(3) 12 Type III Wellspan Health
 
 
No
(11)York Hospital
PO Box 2767

York,PA174052767
23-1352222 		Community teaching hospital PA 501(c)(3) 3 Wellspan Health
 
 
No
(12)Wellspan Surgery & Rehab Hospital
PO Box 2767

York,PA174052767
23-2899911 		Surgery and Rehabilitation Hospital PA 501(c)(3) 3 Wellspan Health
 
 
No
(13)Wellspan Properties
PO Box 2767

York,PA174052767
22-2842252 		Leases facilities to affliates PA 501(c)(3) 12 Type II Wellspan Health Care Services
 
 
No
(14)Ephrata Community Hospital
PO Box 2767

York,PA174052767
23-1370484 		Health Care Services PA 501(c)(3) 3 Wellspan Health
 
 
No
(15)Northern Lancaster County Medical Group
PO Box 2767

York,PA174052767
20-3033058 		Medical and surgical care PA 501(c)(3) 12 Type II Ephrata Community Hospital
 
 
No
(16)Phys Spec of North Lanc Co Med Gr
PO Box 2767

York,PA174052767
45-2537633 		Physician Practices PA 501(c)(3) 12 Type II Northern Lancaster County Medical Group
 
 
No
(17)Good Samaritan Hospital
PO Box 2767

York,PA174052767
23-0794160 		Health Care Services PA 501(c)(3) 3 Wellspan Health
 
 
No
(18)Philhaven
PO Box 2767

York,PA174052767
23-1549922 		Health Care Services PA 501(c)(3) 3 Wellspan Health
 
 
No
(19)Good Samaritan Health Service Foundation
PO Box 2767

York,PA174052767
23-2356151 		Fundraising PA 501(c)(3) 12 Type I Good Samaritan Hospital
 
 
No
(20)Good Samaritan Physician Services
PO Box 2767

York,PA174052767
25-1832359 		Medical and Surgical Care PA 501(c)(3) 10 Good Sam Health Service Foundation
 
 
No
(21)Wellspan Summit Health
PO Box 2767

York,PA174052767
25-1515371 		Integrated Health System PA 501(c)(3) 7 Wellspan Health
 
 
No
(22)Waynesboro Hospital
PO Box 2767

York,PA174052767
23-1360854 		Health Care Services PA 501(c)(3) 3 Wellspan Summit Health
 
 
No
(23)Summit Health Foundation
PO Box 2767

York,PA174052767
83-1196554 		Fundraising for health care system PA 501(c)(3) 12 Type II Wellspan Summit Health
 
 
No
(24)Summit Physician Services
PO Box 2767

York,PA174052767
25-1716306 		Medical and surgical care PA 501(c)(3) 3 Wellspan Summit Health
 
 
No
(25)Chambersburg Health Services
PO Box 2767

York,PA174052767
25-1515376 		Health care services PA 501(c)(3) 12 Type I Wellspan Summit Health
 
 
No
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) Apple Hill Surgical Center Partners

PO Box 2767
York,PA174052767
23-2489452 		Surgical Center PA NA
  		        No     No  
(2) Central PA Alliance Laboratories LLC

PO Box 2767
York,PA174052767
23-2910958 		Ref. Lab PA NA
  		        No     No  
(3) Littlestown Health Care Partners

300 West King Street
Littlestown,PA17340
23-2880464 		Lease facility PA NA
  		        No     No  
(4) Cherry Tree Cancer Center LLP

PO Box 2767
York,PA174052767
23-2915628 		Radiation PA NA
  		        No     No  
(5) The Rehab Center

855 Springdale Drive Suite 20
Exton,PA19341
25-1687903 		Physical Therapy Rehab PA NA
  		        No     No  
(6) Surgery Center Associates

785 5th Avenue
Chambersburg,PA17201
25-1845304 		Physician Services PA Chambersburg Health
  		        No     No  
(7) Summit Surgery Center

785 5th Avenue
Chambersburg,PA17201
25-1845303 		Physician Services PA Chambersburg Health
  		        No     No  
(8) Cumberland Valley Mobile Services LLC

5 South Main Street
Sugarloaf,PA18249
20-0884014 		Mobile medical services PA Chambersburg Health
  		        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,PA174052767
23-2374072 		Dispense Rx's & prov PA NA
  		C corp         No
(2) WellSpan Reciprocal Risk Retention Group

PO Box 2767
York,PA174052767
20-0048457 		Risk Retention Group PA NA
  		C corp         No
(3) York Health Plan

PO Box 2767
York,PA174052767
23-2664989 		Preferred Provider PA NA
  		C corp         No
(4) Wellspan Provider Network

PO Box 2767
York,PA174052767
23-2907828 		Coordinated managed PA NA
  		C corp         No
(5) Apple Hill Condominium Association

PO Box 2767
York,PA174052767
23-2504543 		Condo Mgmt Association PA NA
  		Homeowners Associati         No
(6) North Lanc Co Phys Hosp All

PO Box 2767
York,PA174052767
23-2421885 		Coord Phys & Hospital PA NA
  		C corp         No
(7) GSH Realty Inc

PO Box 2767
York,PA174052767
25-1832359 		Non-res rentals PA NA
  		C corp         No
(8) Ephrata Health Pavilion Condo Assoc

PO Box 2767
York,PA174052767
47-5367279 		Condo association PA Ephrata Hospital
  		C corp         No
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
 
No
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
 
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
 
No
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
(1) Wellspan Health

 b 10,000,000 General Ledger
(2) Wellspan Medical Group

 b 14,500,000 General Ledger
(3) Summit Health Foundation

 c 1,341,038 General Ledger



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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Software Version: 2020v4.0