EX-4.1





 Exhibit 4.1 

NINETEENTH SUPPLEMENTAL INDENTURE (this “Supplemental Indenture”), dated as of July 1, 2019, among CHS/COMMUNITY HEALTH
SYSTEMS, INC., a Delaware corporation (the “Issuer”), the party identified as a New Subsidiary Guarantor on the signature pages hereto (the “New Subsidiary Guarantor”) and REGIONS BANK, as successor Trustee under
the Indenture (the “Trustee”). 
 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 as amended, supplemented,
waived or otherwise modified (the “Indenture”), dated as of November 22, 2011, providing for the issuance of the 8.000% Senior Notes due 2019 (the “Securities”); 

WHEREAS, the undersigned New Subsidiary Guarantor has deemed it advisable and in its best interest to execute and deliver this Supplemental
Indenture, and to become a New Subsidiary Guarantor under the Indenture; and 
 WHEREAS, pursuant to Section 9.01(4) of the Indenture,
the Trustee, the Issuer and the New Subsidiary Guarantor are authorized to execute and deliver this Supplemental Indenture. 
 NOW
THEREFORE, in consideration of the foregoing and for good and valuable consideration, the receipt of which is hereby acknowledged, the Issuer, the New Subsidiary Guarantor and the Trustee mutually covenant and agree for the equal and ratable benefit
of the Holders of the Securities as follows: 
 SECTION 1. Capitalized Terms. Capitalized terms used herein but not defined shall
have the meanings assigned to them in the Indenture. 
 SECTION 2. Guaranties. The New Subsidiary Guarantor hereby agrees to
guarantee the Issuer’s obligations under the Securities on the terms and subject to the conditions set forth in Article 10 of the Indenture and to be bound by all other applicable provisions of the Indenture as a Subsidiary Guarantor. 

SECTION 3. Ratification of Indenture; Supplemental Indentures Part of Indenture. Except as expressly amended hereby, the 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, shall inure to the benefit of the
Trustee and every Holder of Securities heretofore or hereafter authenticated and the Issuer, the Trustee and every Holder of Securities heretofore or hereafter authenticated and delivered shall be bound hereby. 

SECTION 4. Governing Law. THIS SUPPLEMENTAL INDENTURE SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE
OF NEW YORK. 
 SECTION 5. Trustee Makes No Representation. The Trustee makes no representation as to the validity or sufficiency
of this Supplemental Indenture. 












 SECTION 6. Counterparts. The parties 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 7. Effect of Headings. The
Section headings herein are for convenience only and shall not effect the construction of this Supplemental Indenture. 
 [Signature page
follows] 

  
 2 













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

					
	 CHS/COMMUNITY HEALTH SYSTEMS, INC.,

a Delaware corporation

		
	By:    	 	   /s/ Kevin J. Hammons

		 	Kevin J. Hammons
		 	 Senior Vice President, Assistant Chief Financial Officer, Chief Accounting

Officer and Treasurer

	
	New Subsidiary Guarantor:
	 SAN ANGELO HOSPITAL, L.P.,
 a
Delaware limited partnership

		
	By:	 	San Angelo Community Medical Center, LLC, its general partner
			
		 	By:	 	   /s/ Kevin J. Hammons

		 		 	Kevin J. Hammons
		 		 	Senior Vice President and Treasurer
	
	Acting on behalf of the New Subsidiary Guarantor set forth above














 
			
	REGIONS BANK, as Trustee
		
	By:	 	   /s/ Kristine Prall

		 	Kristine Prall
		 	Vice President