EX-4.19



 Exhibit 4.19 

FOURTH SUPPLEMENTAL INDENTURE (this “Supplemental Indenture”), dated as of February 12, 2014, among CHS/COMMUNITY HEALTH SYSTEMS, INC.,
a Delaware corporation (the “Issuer”), each of the parties identified as a New Subsidiary Guarantor on the signature pages hereto (each, a “New Subsidiary Guarantor” and collectively, the “New Subsidiary
Guarantors”) and REGIONS BANK, as 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 July 18, 2012, providing for the issuance of the 7.125% Senior Notes due 2020 (the “Securities”); 

WHEREAS, each of the undersigned New Subsidiary Guarantors 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 Guarantors 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 Guarantors 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. Each 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] 








 IN WITNESS WHEREOF, the parties have caused this Supplemental Indenture to be duly executed as
of this 12th day of February, 2014. 
  

					
	 CHS/Community Health Systems, Inc.,

a Delaware corporation
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President, Secretary & General Counsel

		
	 Armory HMA, LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Bartow HMA, LLC,
 a Florida limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Biloxi H.M.A., LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Brandon HMA, LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Brevard HMA Holdings, LLC,
 a
Florida limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Brevard HMA Hospitals, LLC,
 a
Florida limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Campbell County HMA, LLC,
 a
Tennessee limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Carlisle HMA, LLC,
 a Pennsylvania
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Carolinas JV Holdings, L.P.,
 a
Delaware limited partnership
	 	
		
	By:	 	Carolinas JV Holdings General, LLC, its general partner


 
					
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	


 
					
		
	 Carolinas JV Holdings General, LLC,

a Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Central Florida HMA Holdings, LLC,

a Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Central States HMA Holdings, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Chester HMA, LLC,
 a South Carolina
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Citrus HMA, LLC,
 a Florida limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Clarksdale HMA, LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Cocke County HMA, LLC,
 a Tennessee
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Florida HMA Holdings, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Fort Smith HMA, LLC,
 an
Arkansas limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice
President and Secretary

		
	 Hamlet H.M.A., LLC,
 a North
Carolina limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Health Management Associates, Inc.,

a Delaware corporation
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Health Management General Partner, LLC,

a Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Health Management Associates, LP,
 a
Delaware limited partnership
	 	
		
	By:	 	Health Management General Partner, LLC, its general partner


 
					
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	


 
					
	
	 HMA Fentress County General Hospital, LLC,

a Tennessee limited liability company

			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	









 
					
	 HMA Hospitals Holdings, LP,
 a
Delaware limited partnership
	 	
		
	By:	 	Health Management General Partner, LLC, its general partner


 
					
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	


 
					
		
	 HMA Santa Rosa Medical Center, LLC,

a Florida limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Hospital Management Associates, LLC,

a Florida limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Jackson HMA, LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Jefferson County HMA, LLC,
 a
Tennessee limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Kennett HMA, LLC,
 a Missouri
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Key West HMA, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Knoxville HMA Holdings, LLC,
 a
Tennessee limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Lehigh HMA, LLC,
 a Florida limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Lone Star HMA, L.P.,
 a Delaware
limited partnership
	 	
		
	By:	 	Mesquite HMA General, LLC, its general partner


 
					
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	


 
					
		
	 Madison HMA, LLC,
 a Mississippi
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Melbourne HMA, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Mesquite HMA General, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice
President and Secretary
	 	
		
	 Metro Knoxville HMA, LLC,
 a
Tennessee limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Mississippi HMA Holdings I, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Mississippi HMA Holdings II, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Monroe HMA, LLC,
 a Georgia limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Naples HMA, LLC,
 a Florida limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Poplar Bluff Regional Medical Center, LLC,

a Missouri limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Port Charlotte HMA, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Punta Gorda HMA, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 River Oaks Hospital, LLC,
 a
Mississippi limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Rockledge HMA, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 ROH, LLC,
 a Mississippi limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Sebastian Hospital, LLC,
 a Florida
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
	
	 Sebring Hospital Management Associates, LLC,

a Florida limited liability company

			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Southeast HMA Holdings, LLC,
 a
Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Southwest Florida HMA Holdings, LLC,

a Delaware limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Statesville HMA, LLC,
 a North
Carolina limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 VAN BUREN H.M.A., LLC,
 an Arkansas
limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	 Venice HMA, LLC,
 a Florida limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert

Executive Vice President and Secretary
	 	
		
	 Winder HMA, LLC,
 a Georgia limited
liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	
		
	 Yakima HMA, LLC,
 a
Washington limited liability company
	 	
			
	By:	 	     /s/ Rachel A. Seifert
	 	
		 	 Rachel A. Seifert
 Executive Vice President
and Secretary
	 	









 
					
	Regions Bank, as Trustee	 	
			
	By:	 	     /s/ Paul Williams
	 	
		 	 Paul Williams

Vice President