Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (i)Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
NYU LUTHERAN MEDICAL CENTER |
111839567 | HOSPITAL | Yes | 6,079,991 | 0 | |
Total 1
|
6,079,991 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART IV, SECTION D, LINE 3: | SHORE ROAD RADIOLOGY ASSOCIATES, P.C. IS OPERATED EXCLUSIVELY TO SUPPORT NYU LUTHERAN MEDICAL CENTER. DURING 2014, ALL DECISIONS MADE WITH REGARD TO THE INVESTMENT OF AND THE USE OF INCOME OR ASSETS OF SHORE ROAD RADIOLOGY ASSOCIATES, P.C. WERE MADE BY NYU LUTHERAN MEDICAL CENTER IN ACCORDANCE WITH THE GOVERNING DOCUMENTS OF THE SUPPORTING ORGANIZATION. |
| PART IV, SECTION E, LINE 2A: | THE PURPOSES AND ACTIVITIES OF SHORE ROAD RADIOLOGY ASSOCIATES, P.C. ARE TO SOLELY SUPPORT THE TAX-EXEMPT MISSION OF NYU LUTHERAN MEDICAL CENTER, AN ORGANIZATION DESCRIBED IN IRC SECTION 509(A)(1). SHORE ROAD RADIOLOGY ASSOCIATES, P.C. PROVIDES MEDICALLY NECESSARY SPECIALIZED PHYSICIAN SERVICES TO THE COMMUNITY DEFINED AS THE SAME CATCHMENT AREA AS NYU LUTHERAN MEDICAL CENTER AND UNDER THE DIRECTION AND CONTROL OF NYU LUTHERAN MEDICAL CENTER. |
| PART IV, SECTION E, LINE 2B: | SHORE ROAD RADIOLOGY ASSOCIATES, P.C. PROVIDES SPECIALIZED PATIENT CARE IN SUPPORT OF NYU LUTHERAN MEDICAL CENTER'S MISSION TO PROVIDE COMPREHENSIVE HEALTH CARE TO THE DIVERSE COMMUNITIES OF SOUTHWEST BROOKLYN. SINCE THE PATIENT SERVICES PROVIDED BY SHORE ROAD RADIOLOGY ASSOCIATES, P.C. ARE VIEWED AS INTEGRAL IN MEETING THE HEALTH NEEDS OF THE COMMUNITY, NYU LUTHERAN MEDICAL CENTER WOULD HAVE UNDERTAKEN THESE PATIENT ACTIVITIES EITHER THROUGH DIRECT EMPLOYMENT OF PHYSICIANS OR ALTERNATIVE CONTRACTUAL ARRANGEMENTS WITH THIRD PARTIES IF THE FILING ORGANIZATION WAS NOT INVOLVED. |
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Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 1 | ORGANIZATION'S MISSION SHORE ROAD RADIOLOGY ASSOCIATES, PC ("PC") IS FORMED FOR THE SOLE PURPOSE OF PROMOTING HEALTH FOR THE BENEFIT OF THE COMMUNITY BY SERVING A LARGE AND INDEFINITE CLASS. THE ORGANIZATION PROMOTES HEALTH BY ENGAGING IN THE PROFESSION OF MEDICINE AND PROVIDING MEDICAL SERVICES, IN A MANNER THAT IS EXCLUSIVELY CHARITABLE WITHIN THE MEANING OF SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE PROVISION OF MEDICAL SERVICES HAS BEEN CARRIED ON SINCE THE INCEPTION OF THE ORGANIZATION IN 1983. THE PC OPERATES IN SUPPORT OF NYU LUTHERAN MEDICAL CENTER. NYU LUTHERAN MEDICAL CENTER IS A NOT-FOR-PROFIT CORPORATION ORGANIZED UNDER THE LAWS OF THE STATE OF NEW YORK, AND A CHARITABLE, TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. NYU LUTHERAN MEDICAL CENTER IS AN ACUTE CARE HOSPITAL THAT CONDUCTS CHARITABLE AND HOSPITAL ACTIVITIES. THE PC PROVIDES PROFESSIONAL MEDICAL SERVICES TO PATIENTS, WITHOUT REGARD FOR THE PATIENT'S ABILITY TO PAY. THE ORGANIZATION HAS ADOPTED THE CHARITY CARE POLICY OF NYU LUTHERAN MEDICAL CENTER. |
| FORM 990, PART IV, LINE 12B | SHORE ROAD RADIOLOGY ASSOCIATES, P.C. IS INCLUDED IN A COMBINED AUDITED FINANCIAL STATEMENT FOR THE YEAR ENDING DECEMBER 31ST, 2014. THE COMBINED FINANCIAL STATEMENTS ARE PREPARED IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES IN THE UNITED STATES OF AMERICA ("GAAP"). THE COMBINED FINANCIAL STATEMENTS INCLUDE THE ACCOUNTS OF LUTHERAN MEDICAL CENTER AND ALL OF ITS AFFILIATED ORGANIZATIONS. PER THE INSTRUCTIONS TO THE FORM 990, THE ORGANIZATION IS REQUIRED TO RESPOND "YES" TO PART IV, QUESTION 12B IF THE ORGANIZATION IS PART OF A CONSOLIDATED FINANCIAL STATEMENT. SINCE SELECTING "YES" TO THIS QUESTION MAY BE MISCONSTRUED, THE TAXPAYER IS ATTACHING THIS EXPLANATION TO ITS FORM 990. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION IS A PROFESSIONAL SERVICE CORPORATION ("PC") WITH ONE SHAREHOLDER. UNDER APPLICABLE NYS LAW, ONLY A LICENSED PHYSICIAN MAY HOLD SHARES IN THE PC. DR. JAYANTH RAO, CHAIR OF RADIOLOGY OF LUTHERAN MEDICAL CENTER IS THE SOLE SHAREHOLDER OF THE PC, AND PURSUANT TO A SHAREHOLDER AGREEMENT AMONG DR. RAO, THE PC AND THE MEDICAL CENTER, THE SHAREHOLDER HAS VERY LIMITED AUTHORITY. IN PARTICULAR, THE SHAREHOLDER MAY NOT TRANSFER OR ENCUMBER THE SHARES OR DECLARE DISTRIBUTIONS WITHOUT THE EXPRESS CONSENT OF THE MEDICAL CENTER. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE SOLE SHAREHOLDER HAS THE AUTHORITY TO APPOINT THE DIRECTORS AND OFFICERS OF THE PC. |
| FORM 990, PART VI, SECTION A, LINE 7B | PURSUANT TO THE SHAREHOLDER AGREEMENT, DR. JAYANTH RAO HAS LIMITED AUTHORITY AND ALL DECISIONS ARE CONTROLLED BY LUTHERAN MEDICAL CENTER. |
| FORM 990, PART VI, SECTION A, LINE 8B | THE ORGANIZATION HAS ANSWERED THIS QUESTION "NO" AS THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE FORM 990 IS REVIEWED BY THE VICE PRESIDENT OF FINANCE OF THE ORGANIZATION'S PARENT ORGANIZATION, NYC LUTHERAN MEDICAL CENTER. A COPY OF THE FORM 990 IS PROVIDED TO THE SOLE DIRECTOR, DR. JAYANTH RAO, FOR HIS COMMENT AND REVIEW. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION OPERATES UNDER THE CONFLICT OF INTEREST POLICY OF ITS PARENT ORGANIZATION, NYC LUTHERN MEDICAL CENTER. THE PRESIDENT AND SOLE DIRECTOR, DR. JAYANTH RAO, IS REQUIRED TO DISCLOSE POTENTIAL CONFLICTS OF INTEREST ON AN ANNUAL SURVEY/QUESTIONNAIRE SUBMITTED BY THE MEDICAL CENTER'S GENERAL COUNSEL. THE SUBMITTED QUESTIONNAIRE IS REVIEWED BY THE MEDICAL CENTER'S GENERAL COUNSEL TO ENSURE COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. |
| FORM 990, PART VI, SECTION B, LINE 15 | SENIOR MANAGEMENT AT THE PARENT ORGANIZATION, NYC LUTHERAN MEDICAL CENTER, REGULARLY REVIEWS VARIOUS OBJECTIVE DATA SOURCES THAT FACTOR INTO COMPENSATION FOR EMPLOYED AND CONTRACTED PHYSICIANS AND GROUPS PROVIDING SERVICES TO THE ORGANIZATION. THESE SOURCES INCLUDE NATIONAL AND REGIONAL SURVEY SAMPLES BY PHYSICIAN CLINICAL SPECIALTY, AS PUBLISHED BY SULLIVAN COTTER AND AS PURCHASED FROM OTHER CONSULTANTS, WHICH GUIDE THE ESTABLISHMENT OF FAIR MARKET VALUE FOR EACH PHYSICIAN'S/GROUP'S COMPENSATION LEVEL IN THE ORGANIZATION. WITH RESPECT TO CERTAIN PHYSICIANS WHO MIGHT BE CONSIDERED "LUMINARIES" OR WHOSE COMPENSATION FALLS INTO AN OUTLIER CATEGORY IN THE CLINICAL SPECIALTY, LMC SEEKS ADVICE AND OPINIONS FROM OUTSIDE CONSULTANTS WHO SPECIALIZE IN HIS WORK. IN ADDITION, ALL EMPLOYED AND CONTRACTED PHYSICIANS IN THE PC ARE REQUIRED TO HAVE WRITTEN CONTRACTS, SIGNED BY THE PHYSICIAN AND THE DIRECTOR OF THE ORGANIZATION, DELINEATING THE DUTIES FOR WHICH THEY ARE BEING COMPENSATED. ON A MONTHLY BASIS, THE PHYSICIANS ARE REQUIRED TO SUBMIT TIME REPORTS WHICH DOCUMENT THE TIME SPENT ON VARIOUS ADMINISTRATIVE, SUPERVISORY, TEACHING AND CLINICAL ACTIVITIES. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE TAXPAYER MAKES ITS FORM 990 AND FORM 1023 AVAILABLE TO THE PUBLIC BY RETAINING A COPY OF EACH AT ITS HEAD OFFICES. ANY INDIVIDUAL REQUESTING A COPY OF THESE DOCUMENTS IS PROVIDED THAT COPY ON THE SAME BUSINESS DAY. THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION DOES NOT OBTAIN AUDITED FINANCIAL STATEMENTS SO THESE ARE NOT MADE AVAILABLE TO THE PUBLIC. |
| PART VI, SECTION B, LINE 13 & 14 | THE ORGANIZATION OPERATES UNDER THE WHISTLEBLOWER AND DOCUMENT RETENTION POLICY OF ITS PARENT ORGANIZATION, NYU LUTHERAN MEDICAL CENTER. |
| FORM 990, PART IX, LINE 11G | OUTSIDE PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 1,658,428. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,658,428. |
| FORM 990, PART XI, LINE 9: | TRANSFERS OF NET ASSETS FROM RELATED ENTITIES 2,024,956. |
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