EX-4.5





 Exhibit 4.5 

SIXTH SUPPLEMENTAL INDENTURE, (this “Supplemental Indenture”) dated as of July 1, 2019, by and among CHS/Community
Health Systems, Inc., a Delaware corporation (“Issuer”), the party that is a signatory hereto as a Guarantor (the “Guaranteeing Subsidiary”), Credit Suisse AG, as Collateral Agent, and Regions Bank, as Trustee under
the Indenture referred to below. 
 W I T N E S S E T H: 

WHEREAS, each of the Issuer, the Guarantors and the Trustee have heretofore executed and delivered an indenture dated as of March 16,
2017 (the “Base Indenture”) and a first supplemental indenture dated March 16, 2017 (the “First Supplemental Indenture”) providing for the issuance on such date of an initial aggregate principal amount
of $2,200,000,000 of 6.250% Senior Secured Notes due 2023, and a second supplemental indenture dated May 12, 2017 (the “Second Supplemental Indenture” and, together with the Base Indenture and the First Supplemental Indenture,
as amended, supplemented, waived or otherwise modified, the “Indenture”) providing for the issuance on such date of an additional aggregate principal amount of $900,000,000 of 6.250% Senior Secured Notes due 2023, for an total
aggregate principal amount of $3,100,000 of 6.250% Senior Secured Notes due 2023 (the “Notes”) of the Issuer; 
 WHEREAS,
the First Supplemental Indenture provides that the Guaranteeing Subsidiary shall, as to and to the extent provided therein, execute and deliver to the Trustee and the Collateral Agent a supplemental indenture pursuant to which the Guaranteeing
Subsidiary shall unconditionally guarantee all of the Issuer’s Obligations under the Notes and the First Supplemental Indenture on the terms and conditions set forth herein and under the First Supplemental Indenture (the “Note
Guarantee”), each on the terms and conditions set forth herein; and 
 WHEREAS, pursuant to Section 9.1 of the First Supplemental
Indenture, the Issuer, any Guarantor and the Trustee are authorized to execute and deliver this Supplemental Indenture to amend or supplement the First Supplemental Indenture, without the consent of any Holder; 

NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt of which is hereby acknowledged,
the Issuer, the Guaranteeing Subsidiary and the Trustee mutually covenant and agree for the benefit of the Trustee, the Collateral Agent and the Holders of the Notes as follows: 

ARTICLE I 
 DEFINITIONS 

SECTION 1.1. Defined Terms. As used in this Supplemental Indenture, terms defined in the Indenture or the First Supplemental
Indenture, dated March 16, 2017, or in the preamble or recitals hereto are used herein as therein defined. The words “herein,” “hereof” and “hereby” and other words of similar import used in this Supplemental
Indenture refer to this Supplemental Indenture as a whole and not to any particular section hereof. 












 ARTICLE II 

AGREEMENT TO BE BOUND; GUARANTEE 

SECTION 2.1. Agreement to be Bound. The Guaranteeing Subsidiary hereby becomes a party to the First Supplemental Indenture as a
“Guarantor” and as such will have all of the rights and be subject to all of the obligations and agreements of a “Guarantor” under the First Supplemental Indenture. 

SECTION 2.2. Guarantee. The Guaranteeing Subsidiary agrees, on a joint and several basis with all the existing Guarantors, to
fully, unconditionally and irrevocably Guarantee to each Holder of the Notes, the Trustee and the Collateral Agent the Guaranteed Obligations pursuant to Article X of the First Supplemental Indenture as and to the extent provided for therein.

 ARTICLE III 
 MISCELLANEOUS

 SECTION 3.1. Notices. All notices and other communications to the Guarantors shall be given as provided in the First
Supplemental Indenture. 
 SECTION 3.2. Merger and Consolidation. The Guaranteeing Subsidiary shall not sell or otherwise
dispose of all or substantially all of its assets to, or consolidate with or merge with or into, another Person (other than the Issuer or any Restricted Subsidiary that is a Guarantor or becomes a Guarantor concurrently with the transaction) except
in accordance with Section 4.1(e) of the First Supplemental Indenture. 
 SECTION 3.3. Release of
Guarantee. The Note Guarantees hereunder may be released in accordance with Section 10.2 of the First Supplemental Indenture. 

SECTION 3.4. Parties. Nothing expressed or mentioned herein is intended or shall be construed to give any Person, firm or
corporation, other than the Holders and the Trustee, any legal or equitable right, remedy or claim under or in respect of this Supplemental Indenture or the Indenture or any provision herein or therein contained. 

SECTION 3.5. Governing Law. This Supplemental Indenture shall be governed by, and construed in accordance with, the laws of the
State of New York. 
 SECTION 3.6. Severability. In case any provision in this Supplemental Indenture shall be invalid, illegal
or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby and such provision shall be ineffective only to the extent of such invalidity, illegality or
unenforceability. 
 SECTION 3.7. Benefits Acknowledged. The Guaranteeing Subsidiary’s Note Guarantee is subject to the
terms and conditions set forth in the First Supplemental Indenture. The Guaranteeing Subsidiary acknowledges that it will receive direct and indirect benefits from the financing arrangements contemplated by the First Supplemental Indenture and this
Supplemental Indenture and that the guarantee and waivers made by it pursuant to its Note Guarantee are knowingly made in contemplation of such benefits. 

  
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 SECTION 3.8. Ratification of Indenture; Supplemental Indentures Part of
Indenture. Except as expressly amended hereby, the First Supplemental Indenture is in all respects ratified and confirmed and all the terms, conditions and provisions thereof shall remain in full force and effect. This Supplemental Indenture
shall form a part of the Indenture for all purposes, and every Holder of Notes heretofore or hereafter authenticated and delivered shall be bound hereby. 

SECTION 3.9. The Trustee and the Collateral Agent. Neither the Trustee nor the Collateral Agent make any representation or
warranty as to the validity or sufficiency of this Supplemental Indenture or with respect to the recitals contained herein, all of which recitals are made solely by the other parties hereto. 

SECTION 3.10. Counterparts. The parties hereto may sign any number of copies of this Supplemental Indenture. Each signed copy
shall be an original, but all of them together represent the same agreement. The exchange of copies of this Supplemental Indenture and of signature pages by facsimile or other electronic transmission shall constitute effective execution and delivery
of this Supplemental Indenture as to the parties hereto and may be used in lieu of the original Supplemental Indenture for all purposes. Signatures of the parties hereto transmitted by facsimile or other electronic transmission shall be deemed to be
their original signatures for all purposes. 
 SECTION 3.11. Execution and Delivery. The Guaranteeing Subsidiary agrees that
its Note Guarantee shall remain in full force and effect notwithstanding any absence on each Note of a notation of any such Note Guarantee. 

SECTION 3.12. Headings. The headings of the Articles and the Sections in this Supplemental Indenture are for convenience of
reference only and shall not be deemed to alter or affect the meaning or interpretation of any provisions hereof. 
 [Signature page
follows] 

  
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 IN WITNESS WHEREOF, the parties hereto have caused this Supplemental Indenture to be duly
executed as of the date first above written. 
  

					
	 SAN ANGELO HOSPITAL, L.P.,

as a Guarantor

		
	By:	 	 San Angelo Community Medical Center,

LLC, its general partner    

			
		 	By:	 	  /s/ Kevin J. Hammons                    
		 		 	Kevin J. Hammons
		 		 	Senior Vice President and Treasurer


  

			
	Acknowledged by:
	
	CHS/COMMUNITY HEALTH SYSTEMS, INC.
		
	By:	 	  /s/ Kevin J. Hammons                            
		 	Kevin J. Hammons
		 	 Senior Vice President, Assistant
 Chief
Financial Officer, Chief
 Accounting Officer and Treasurer














 
			
	 REGIONS BANK,
 as
Trustee

		
	By:	 	   /s/ Kristine Prall

		 	  Kristine Prall
		 	  Vice President














 
			
	 CREDIT SUISSE AG, CAYMAN ISLANDS

BRANCH, as Collateral Agent

		
	By:	 	  /s/ Lingzi
Huang                                    
		 	  Name: Lingzi Huang
		 	  Title:   Authorized Signatory
		
	By:	 	  /s/ Marc
Zihlmann                                 
		 	  Name: Marc Zihlmann
		 	  Title:   Authorized Signatory