Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HEALTH VENTURES
Employer identification number
91-1350776
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
No
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(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 in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
(A)
PEACEHEALTH
910939479
501(C)(3)
Yes
8,500,000
Total
8,500,000
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HEALTH VENTURES
Employer identification number
91-1350776
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
PEACEHEALTH, A WASHINGTON NON-PROFIT CORPROATION, WHICH IS EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, IS THE SOLE MEMBER CORPORATION OF HEALTH VENTURES.
FORM 990, PART VI, SECTION A, LINE 7A
PEACEHEALTH, A 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF HEALTH VENTURES AND ELECTS THE HEALTH VENTURES BOARD. AS THE SOLE MEMBER CORPORATION, PEACEHEALTH HAS CERTAIN ADDITIONAL RIGHTS, INCLUDING APPROVING ALL HEALTH VENTURES BOARD MEMBER APPOINTMENTS, APPROVING DISSOLUTION OF HEALTH VENTURES, AND APPROVING CHANGES TO HEALTH VENTURES' ARTICLES AND BYLAWS.
FORM 990, PART VI, SECTION A, LINE 7B
PEACEHEALTH, A 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF HEALTH VENTURES AND ELECTS THE HEALTH VENTURES BOARD. AS THE SOLE MEMBER CORPORATION, PEACEHEALTH HAS CERTAIN ADDITIONAL RIGHTS, INCLUDING APPROVING ALL HEALTH VENTURES BOARD MEMBER APPOINTMENTS, APPROVING DISSOLUTION OF HEALTH VENTURES, AND APPROVING CHANGES TO HEALTH VENTURES' ARTICLES AND BYLAWS.
FORM 990, PART VI, SECTION B, LINE 11
FORM 990 REVIEW PROCESS: HEALTH VENTURES' CEO DISTRIBUTES A WORKING DRAFT OF THE 990 FILING TO THE HEALTH VENTURES BOARD FOR REVIEW AND INPUT. BOARD INPUT IS INCORPORATED INTO THE FINAL 990 FILING, WHICH IS THEN REVIEWED AGAIN BY THE CEO AND SIGNED. THE BOARD RECEIVES SIGNED COPIES OF THE FORM 990 PRIOR TO SUBMISSION TO THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
A FORMAL CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO HEALTH VENTURES BOARD MEMBERS AND OFFICERS AT LEAST ANNUALLY. RESPONSES ARE REVIEWED BY COUNSEL AND ANY PERCEIVED OR REAL CONFLICTS OF CONCERN ARE BROUGHT TO THE BOARD'S ATTENTION FOR RESOLUTION. BOARD MEMBERS AND OFFICERS ARE OBLIGATED TO BRING ANY CHANGES IN STATUS VIS-A-VIS THE CONFLICT OF INTEREST POLICY TO THE BOARD'S ATTENTION FOR REVIEW AND DISPOSITION BETWEEN SURVEY PERIODS. ADDITIONAL INFORMATION: THE FOLLOWING INDIVIDUALS SERVE AS DIRECTORS FOR PEACEHEALTH AND A JOINT VENTURE OWNED BY HEALTH VENTURES: NAME OF PERSON: NANCY STEIGER DESCRIPTION OF POSITION: SERVES AS A DIRECTOR OF MT BAKER IMAGING, PLLC. NAME OF PERSON: WENDY APLAND DESCRIPTION OF POSITION: SERVES AS A DIRECTOR OF OREGON IMAGING CENTERS, LLC AND RIVERBEND AMBULATORY SURGERY CENTER, LLC. NAME OF PERSON: JOSIAH JOHNSON DESCRIPTION OF POSITION: SERVES AS A DIRECTOR OF SOUTHWEST WASHINGTON REGIONAL SURGERY CENTER, LLC. NAME OF PERSON: GORDON EDWARDS DESCRIPTION OF POSITION: SERVES AS A DIRECTOR OF SOUTHWEST WASHINGTON REGIONAL SURGERY CENTER, LLC. NAME OF PERSON: HOWARD GRAMAN, M.D. DESCRIPTION OF POSITION: SERVES AS A DIRECTOR OF COLUMBIA INTEGRATED NETWORK LLC.
FORM 990, PART VI, SECTION B, LINE 15
PEACEHEALTH IS THE SOLE MEMBER OF HEALTH VENTURES. HEALTH VENTURES HAS NO EMPLOYEES. EMPLOYEES OF PEACEHEALTH SERVE AS OFFICERS OF HEALTH VENTURES. THE INDEPENDENT NATIONAL CONSULTING FIRM OF SULLIVAN AND COTTER IS RETAINED BY THE EXECUTIVE COMMITTEE OF THE PEACEHEALTH BOARD, WHICH ALSO SERVES AS THE COMPENSATION COMMITTEE. ALL COMMITTEE MEMBERS ARE SUBJECT TO THE CONFLICT OF INTEREST POLICIES AND RECUSE THEMSELVES IN THE EVENT OF A POTENTIAL CONFLICT. SULLIVAN COTTER IS REGULARLY AND CONSISTENTLY UTILIZED TO PREPARE AND ANALYZE COMPENSATION COMPARABILITY DATA FOR OFFICERS, KEY EXECUTIVES AND DISQUALIFIED PERSONS DESCRIBED IN THE INTERMEDIATE SANCTION REGULATIONS. THOSE REPORTS ARE PROVIDED TO THE EXECUTIVE COMMITTEE OF THE PEACEHEALTH BOARD OF DIRECTORS FOR COMPENSATION APPROVALS TO ENSURE THE FAIR MARKET VALUE OF COMPENSATION FOR THESE INDIVIDUALS, AND THESE APPROVALS ARE DOCUMENTED IN COMMITTEE MINUTES. THIS RESPONSE REFERS TO PART VI, LINES 15A AND 15B.
FORM 990, PART VI, SECTION C, LINE 18
ALL GOVERNING DOCUMENTS, INCLUDING THE CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE ON REQUEST.
FORM 990, PART VI, SECTION C, LINE 19
ALL GOVERNING DOCUMENTS, INCLUDING THE CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE ON REQUEST. FORM 990, PART VII, SECTION A, LINE 1A, COLUMN(B) - AVERAGE HOURS PER WEEK FOR RELATED ORGANIZATIONS: THE INDIVIDUALS BELOW COMPLETED THE FOLLOWING AVERAGE HOURS PER WEEK AT THE RELATED ORGANIZATION, PEACEHEALTH. ALAN YORDY 40.00 HOURS STUART HENNESSEY 40.00 HOURS JOSIAH JOHNSON 40.00 HOURS KEVIN WALSTROM 40.00 HOURS JOHN HILL 40.00 HOURS NANCY STEIGER 40.00 HOURS JOE KORTUM 40.00 HOURS PETER ADLER 40.00 HOURS CRAIG RIXON 40.00 HOURS KERRY RADCLIFFE 40.00 HOURS GORDON EDWARDS 40.00 HOURS WENDY APLAND 40.00 HOURS HOWARD GRAMAN 40.00 HOURS
FORM 990, PART XI, LINE 9:
PARTNERSHIP BOOK/TAX DIFFERENCES -1,233,025. OWNERSHIP INCREASE IN JOINT VENTURES 1,778,168. UNRESTRICTED NET ASSETS FROM JOINT VENTURES -111,149.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.