EX-4.9





 Exhibit 4.9 

SECOND 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, the Trustee and the Collateral Agent have heretofore executed and delivered an indenture dated
as of March 6, 2019 (as amended, supplemented, waived or otherwise modified, the “Indenture”), providing for the issuance on such date of an aggregate principal amount of $1,600,809,000 of 8.000% Senior Secured Notes due 2026
(the “Notes”) of the Issuer; 
 WHEREAS, the Indenture provides that the Guaranteeing Subsidiary shall 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 Indenture on the terms and conditions set
forth herein and under the Indenture (the “Note Guarantee”), each on the terms and conditions set forth herein; and 

WHEREAS, pursuant to Section 9.1 of the Indenture, the Issuer, any Guarantor, the Collateral Agent and the Trustee
are authorized to execute and deliver this Supplemental Indenture to amend or supplement the 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, the Collateral Agent 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 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 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 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 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 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 Indenture. 
 SECTION 3.3. Release of Guarantee. The Note Guarantees hereunder
may be released in accordance with Section 10.2 of the 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 Indenture. The Guaranteeing Subsidiary acknowledges that it will receive direct and indirect benefits from the financing arrangements contemplated by the
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. 

SECTION 3.8. 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, 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. 

  
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 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

		 	  Name: Kristine Prall
		 	  Title:   Vice President














 
			
	CREDIT SUISSE AG, CAYMAN ISLANDS BRANCH, as Collateral Agent
		
	By:	 	   /s/ Lingzi Huang

		 	  Name: Lingzi Huang
		 	  Title:  Authorized Signatory
		
	By:	 	   /s/ Andrew Griffin

		 	  Name: Andrew Griffin
		 	  Title:   Authorized Signatory