Exhibit 4.1

 

Execution Version

 

Third Supplemental Indenture

 

THIRD SUPPLEMENTAL INDENTURE, dated as of November 7, 2011 (this “Supplemental Indenture”), among Emergency Medical Services Corporation, a Delaware corporation (as successor by merger to CDRT Merger Sub, Inc., the “Company”), as issuer, the Subsidiary Guarantors party hereto and Wilmington Trust, National Association (as successor by merger to Wilmington Trust FSB), as Trustee under the Indenture referred to below.

 

W I T N E S S E T H:

 

WHEREAS, the Company, the Subsidiary Guarantors party thereto from time to time and the Trustee are parties to an Indenture, dated as of May 25, 2011 (as supplemented by the First Supplemental Indenture (as defined below) and the Second Supplemental Indenture, dated as of May 25, 2011, among the Company, the Subsidiary Guarantors party thereto and the Trustee, and as further amended, supplemented, waived or otherwise modified from time to time, the “Indenture”), providing for, among other things, the issuance of Notes in series;

 

WHEREAS, the Company and the Trustee are parties to the first supplemental indenture to the Indenture, dated as of May 25, 2011 (as amended, supplemented, waived or otherwise modified from time to time, the “First Supplemental Indenture”), providing for the issuance of 8.125% Senior Notes due 2019 of the Company;

 

WHEREAS, the Company and the Subsidiary Guarantors desire to execute and deliver an amendment to the Indenture for the purposes of conforming the text of paragraph 4 of the First Supplemental Indenture to the “Description of Notes” section of the Offering Memorandum; and

 

WHEREAS, pursuant to Section 901(9) of the Indenture, the parties hereto are authorized to execute and deliver this Supplemental Indenture to amend 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 Company, the Subsidiary Guarantors and the Trustee mutually covenant and agree for the benefit of the Holders of the Notes as follows:

 

1.  Defined Terms.  As used in this Supplemental Indenture, terms defined in the Indenture or in the preamble or recital 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.

 

2.  Amendment of Paragraph 4 of the First Supplemental Indenture.  Paragraph 4 of the First Supplemental Indenture is hereby amended, pursuant to Section 901(9) of the Indenture, to delete “December 15” in each place in which it appears in such paragraph and to replace each such deletion with “November 15”.

 











 

3.  Governing Law.  THIS SUPPLEMENTAL INDENTURE SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF NEW YORK.  THE TRUSTEE, THE COMPANY, ANY OTHER OBLIGOR IN RESPECT OF THE NOTES AND (BY THEIR ACCEPTANCE OF THE NOTES) THE HOLDERS AGREE TO SUBMIT TO THE JURISDICTION OF ANY UNITED STATES FEDERAL OR STATE COURT LOCATED IN THE BOROUGH OF MANHATTAN, IN THE CITY OF NEW YORK IN ANY ACTION OR PROCEEDING ARISING OUT OF OR RELATING TO THIS SUPPLEMENTAL INDENTURE.

 

4.  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.  The Trustee makes no representation or warranty as to the validity or sufficiency of this Supplemental Indenture or as to the accuracy of the recitals to this Supplemental Indenture.

 

5.  Counterparts.  The parties hereto may sign one or more copies of this Supplemental Indenture in counterparts, all of which together shall constitute one and the same agreement.

 

6.  Headings.  The Section headings herein are for convenience of reference only and shall not be deemed to alter or affect the meaning or interpretation of any provisions hereof.

 

2











 

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

 

	
 
    	
EMERGENCY   MEDICAL SERVICES CORPORATION
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
A1   LEASING, INC.
    
	
 
    	
ABBOTT   AMBULANCE, INC.
    
	
 
    	
ADAM   TRANSPORTATION SERVICE, INC.
    
	
 
    	
AFFILION, INC.
    
	
 
    	
AIR   AMBULANCE SPECIALISTS, INC.
    
	
 
    	
AMBULANCE   ACQUISITION, INC.
    
	
 
    	
AMERICAN EMERGENCY PHYSICIANS MANAGEMENT, INC.
    
	
 
    	
AMERICAN   INVESTMENT ENTERPRISES, INC.
    
	
 
    	
AMERICAN   MEDICAL PATHWAYS, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE AMBULANCE SERVICE, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE MID ATLANTIC, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE OF COLORADO, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF CONNECTICUT, INCORPORATED
    
	
 
    	
AMERICAN   MEDICAL RESPONSE OF GEORGIA, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE HOLDINGS, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE OF ILLINOIS, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE OF INLAND EMPIRE
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
AMERICAN MEDICAL RESPONSE MANAGEMENT, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE NORTHWEST, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF MASSACHUSETTS, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF NORTH   CAROLINA, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF OKLAHOMA, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF SOUTH   CAROLINA, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF SOUTHERN CALIFORNIA
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF TENNESSEE, INC.
    
	
 
    	
AMERICAN MEDICAL RESPONSE OF TEXAS, INC.
    
	
 
    	
AMERICAN   MEDICAL RESPONSE WEST
   AMERICAN MEDICAL RESPONSE, INC.
    
	
 
    	
AMR HOLDCO, INC.
    
	
 
    	
ARIZONA OASIS ACQUISITION, INC.
    
	
 
    	
ASSOCIATED AMBULANCE SERVICE, INC.
    
	
 
    	
ATLANTIC AMBULANCE SERVICES ACQUISITION, INC.
    
	
 
    	
ATLANTIC/KEY WEST AMBULANCE, INC.
    
	
 
    	
ATLANTIC/PALM BEACH AMBULANCE, INC.
    
	
 
    	
BESTPRACTICES, INC.
    
	
 
    	
BLYTHE AMBULANCE SERVICE
    
	
 
    	
BROWARD AMBULANCE, INC.
    
	
 
    	
DESERT VALLEY MEDICAL TRANSPORT, INC.
    
	
 
    	
EHR MANAGEMENT CO.
    
	
 
    	
EMCARE ANESTHESIA PROVIDERS, INC.
    
	
 
    	
EMCARE HOLDCO, INC.
    
	
 
    	
EMCARE HOLDINGS, INC.
    
	
 
    	
EMCARE, INC.
    
	
 
    	
EMCARE OF CALIFORNIA, INC.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
EMCARE PHYSICIAN PROVIDERS, INC.
    
	
 
    	
EMCARE PHYSICIAN SERVICES, INC.
    
	
 
    	
EMERGENCY MEDICINE EDUCATION SYSTEMS, INC.
    
	
 
    	
FIVE COUNTIES AMBULANCE SERVICE, INC.
    
	
 
    	
FLORIDA EMERGENCY PARTNERS, INC.
    
	
 
    	
FOUNTAIN AMBULANCE SERVICE, INC.
    
	
 
    	
HANK’S ACQUISITION CORP.
    
	
 
    	
HEALTHCARE ADMINISTRATIVE SERVICES, INC.
    
	
 
    	
HEMET VALLEY AMBULANCE SERVICE, INC.
    
	
 
    	
HERREN ENTERPRISES, INC.
    
	
 
    	
HOLIDAY ACQUISITION COMPANY, INC.
    
	
 
    	
INTERNATIONAL LIFE SUPPORT, INC.
    
	
 
    	
KUTZ AMBULANCE SERVICE, INC.
    
	
 
    	
LIFECARE AMBULANCE SERVICE, INC.
    
	
 
    	
LIFEFLEET SOUTHEAST, INC.
    
	
 
    	
MEDEVAC MEDICAL RESPONSE, INC.
    
	
 
    	
MEDEVAC MIDAMERICA, INC.
    
	
 
    	
MEDIC ONE AMBULANCE SERVICES, INC.
    
	
 
    	
MEDIC ONE OF COBB, INC.
    
	
 
    	
MEDI-CAR AMBULANCE SERVICE, INC.
    
	
 
    	
MEDI-CAR SYSTEMS, INC.
    
	
 
    	
MEDICWEST AMBULANCE, INC.
    
	
 
    	
MEDICWEST HOLDINGS, INC.
    
	
 
    	
MEDLIFE EMERGENCY MEDICAL SERVICE, INC.
    
	
 
    	
MERCY AMBULANCE OF EVANSVILLE, INC.
    
	
 
    	
MERCY LIFE CARE
    
	
 
    	
MERCY, INC.
    
	
 
    	
METRO AMBULANCE   SERVICE (RURAL), INC.
    
	
 
    	
METRO AMBULANCE SERVICE, INC.
    
	
 
    	
METRO AMBULANCE   SERVICES, INC.
    
	
 
    	
MIDWEST AMBULANCE MANAGEMENT COMPANY
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
MOBILE MEDIC AMBULANCE SERVICE, INC.
    
	
 
    	
NEVADA RED ROCK AMBULANCE, INC.
    
	
 
    	
NEVADA RED ROCK HOLDINGS, INC.
    
	
 
    	
PARAMED, INC.
    
	
 
    	
PARK AMBULANCE SERVICE INC.
    
	
 
    	
PHYSICIAN ACCOUNT MANAGEMENT, INC.
    
	
 
    	
PHYSICIANS & SURGEONS AMBULANCE SERVICE, INC.
    
	
 
    	
PROVIDER ACCOUNT MANAGEMENT, INC.
    
	
 
    	
PUCKETT AMBULANCE SERVICE, INC.
    
	
 
    	
RADIOLOGY STAFFING SOLUTIONS, INC.
    
	
 
    	
RADSTAFFING MANAGEMENT SOLUTIONS, INC.
    
	
 
    	
RANDLE EASTERN AMBULANCE SERVICE, INC.
    
	
 
    	
REIMBURSEMENT TECHNOLOGIES, INC.
    
	
 
    	
RIVER MEDICAL INCORPORATED
    
	
 
    	
SEMINOLE COUNTY AMBULANCE, INC.
    
	
 
    	
SPRINGS AMBULANCE SERVICE, INC.
    
	
 
    	
STAT HEALTHCARE, INC.
    
	
 
    	
SUNRISE HANDICAP TRANSPORT CORP.
    
	
 
    	
TEK AMBULANCE, INC.
    
	
 
    	
TIDEWATER AMBULANCE SERVICE, INC.
    
	
 
    	
TROUP COUNTY EMERGENCY MEDICAL SERVICES, INC.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
EMERGENCY   MEDICAL SERVICES LP CORPORATION
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
						


 

[Signature Page to Third Supplemental Indenture]

 












 

	
 
    	
ACCESS   2 CARE, LLC
    
	
 
    	
 
    
	
 
    	
By: MISSION CARE SERVICES, LLC as manager of Access 2 Care, LLC
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE, INC. as manager of Mission Care   Services, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
AMR BROCKTON, L.L.C.
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE OF MASSACHUSETTS, INC., as manager   and sole member of AMR Brockton, L.L.C.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
AMERICAN MEDICAL RESPONSE DELAWARE VALLEY, LLC
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE MID-ATLANTIC, INC., as sole member   of American Medical Response Delaware Valley, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
						


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
APEX   ACQUISITION LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC. as sole member of Apex   Acquisition LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
EMS   MANAGEMENT LLC
    
	
 
    	
 
    
	
 
    	
By: AMR HOLDCO, INC. and EMCARE   HOLDCO, INC., it members
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
EVERRAD,   LLC
    
	
 
    	
 
    
	
 
    	
By: TEMPLETON READINGS, LLC, as sole member of EverRad, LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC., as sole member of Templeton Readings, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
MEDASSOCIATES,   LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC., as sole member of   MedAssociates, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name: 
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title: 
    	
Secretary
    
					


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
MISSION   CARE OF ILLINOIS, LLC
    
	
 
    	
 
    
	
 
    	
By: MISSION CARE SERVICES, LLC, as the manager of Mission Care of   Illinois
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE, INC., as the manager of Mission Care   Services, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
MISSION   CARE OF MISSOURI, LLC
    
	
 
    	
 
    
	
 
    	
By: MISSION CARE SERVICES, LLC, as the manager of Mission Care of   Missouri, LLC
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE, INC., as the manager of Mission Care   Services, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
MISSION   CARE SERVICES, LLC
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL RESPONSE, INC., as the manager of Mission Care   Services, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
								


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
MSO   NEWCO, LLC
    
	
 
    	
 
    
	
 
    	
By: APEX ACQUISITION LLC, as sole member of MSO Newco, LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC. as sole member of Apex   Acquisition LLC
    
	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
PINNACLE   CONSULTANTS MID-ATLANTIC, L.L.C.
    
	
 
    	
 
    
	
 
    	
By: APEX ACQUISITION LLC, as sole member of Pinnacle Consultants   Mid-Atlantic, L.L.C.
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC. as sole member of Apex   Acquisition LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
PROVIDACARE,   L.L.C.
    
	
 
    	
 
    
	
 
    	
By: AMERICAN MEDICAL PATHWAYS, INC., as sole member of ProvidaCare,   L.L.C.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
					


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
REGIONAL   EMERGENCY SERVICES, L.P.
    
	
 
    	
 
    
	
 
    	
By: FLORIDA EMERGENCY PARTNERS, INC., as general partner of Regional   Emergency Services, L.P.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
SUN   DEVIL ACQUISITION LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC. as sole member of Sun Devil Acquisition LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
TEMPLETON   READINGS, LLC
    
	
 
    	
 
    
	
 
    	
By: EMCARE, INC. as sole member of Templeton Readings, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
GOLD   COAST AMBULANCE SERVICE
   V.I.P. PROFESSIONAL SERVICES, INC.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/ Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
								


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
METROPOLITAN   AMBULANCE SERVICE
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
EMS   OFFSHORE MEDICAL SERVICES, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
SEAWALL   ACQUISITION, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
CLINICAL   PARTNERS MANAGEMENT COMPANY, LLC
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
NORTHWOOD   ANESTHESIA ASSOCIATES, L.L.C.
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Craig A. Wilson
    
	
 
    	
 
    	
Name:
    	
Craig   A. Wilson
    
	
 
    	
 
    	
Title:
    	
Secretary
    
							


 

[Signature Page to Third Supplemental Indenture]

 











 

	
 
    	
WILMINGTON   TRUST, NATIONAL ASSOCIATION, as Trustee
    
	
 
    	
 
    
	
 
    	
 
    
	
 
    	
By:
    	
/s/   Joseph O’Donnell
    
	
 
    	
 
    	
Name:
    	
Joseph   O’Donnell
    
	
 
    	
 
    	
Title
    	
Vice   President
    


 

[Signature Page to Third Supplemental Indenture]