EX-4.4




 Exhibit 4.4 

EXECUTION VERSION 
 FIRST
SUPPLEMENTAL INDENTURE 
 dated as of November 19, 2019 

among 
 CHS/COMMUNITY HEALTH
SYSTEMS, INC., 
 the GUARANTORS party hereto, 

REGIONS BANK, 
 as Trustee

 and 
 CREDIT SUISSE
AG, 
 as Collateral agent 

to the 
 INDENTURE 

dated as of March 6, 2019 

among 
 CHS/COMMUNITY HEALTH
SYSTEMS, INC., 
 the GUARANTORS party hereto, 

REGIONS BANK, 
 as Trustee

 and 
 CREDIT SUISSE
AG, 
 as Collateral agent 
  

 
  

Additional $500,000,000 8.000% Senior Secured Notes due 2026 
  

 
  











 This FIRST SUPPLEMENTAL INDENTURE (this “First Supplemental Indenture”),
dated as of November 19, 2019, among CHS/COMMUNITY HEALTH SYSTEMS, INC., a Delaware corporation (the “Issuer”), the GUARANTORS party hereto (the “Guarantors”), REGIONS BANK, an Alabama banking corporation (the
“Trustee”), and CREDIT SUISSE AG, as collateral agent (the “Collateral Agent”). 
 RECITALS 

WHEREAS, the Issuer, the Guarantors, the Trustee and the Collateral Agent have heretofore executed and delivered an Indenture, dated as of
March 6, 2019 (the “Indenture”), providing for the issuance on such date by the Issuer of $1,600,809,000 aggregate principal amount of the Issuer’s 8.000% Senior Secured Notes due 2026 (the “Initial
Notes”); 
 WHEREAS, Section 2.1(a) of the Indenture provides, among other things, that the Issuer may issue, from time to
time, in accordance with the provisions of the Indenture, Additional Notes; 
 WHEREAS, the Issuer has entered into that certain Purchase
Agreement, dated as of November 4, 2019, among the Issuer, the Guarantors and Credit Suisse Securities (USA) LLC, as representative of the initial purchasers identified therein, pursuant to which, among other things, on the date hereof, the
Issuer is issuing $500,000,000 of 8.000% Senior Secured Notes due 2026 as Additional Notes (the “November 2019 Additional Notes”) as permitted by Section 2.1 of the Indenture; 

WHEREAS, the November 2019 Additional Notes will have identical terms and conditions as the Initial Notes, other than issue date, issue price
and the date from which interest will accrue; 
 WHEREAS, the Issuer intends by this First Supplemental Indenture to create and provide for
the issuance of the November 2019 Additional Notes as Additional Notes under the Indenture; 
 WHEREAS, pursuant to Section 9.1(7) of
the Indenture, the Issuer, the Guarantors, the Trustee, and the Collateral Agent are authorized to execute and deliver this First Supplemental Indenture to provide for the issuance of the November 2019 Additional Notes under the Indenture without
notice to or consent of any Holder; and 
 WHEREAS, all things necessary to make the November 2019 Additional Notes, when executed by the
Issuer and authenticated and delivered by the Trustee, issued upon the terms and subject to the conditions set forth hereinafter and in the Indenture and delivered as provided in the Indenture against payment therefor, valid, binding and legal
obligations of the Issuer according to their terms, and all actions required to be taken by the Issuer under the Indenture to make this First Supplemental Indenture a valid, binding and legal agreement of the Issuer, have been done. 

NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the sufficiency and adequacy of which are
hereby acknowledged, the parties hereto hereby agree as follows: 
 ARTICLE 1 

DEFINITIONS AND INCORPORATION BY REFERENCE 

Section 1.01 Definitions. 

(a) All capitalized terms used herein and not otherwise defined herein shall have the meanings ascribed thereto in the Indenture. 

(b) For all purposes of this First Supplemental Indenture, except as otherwise herein expressly provided or unless the context otherwise
requires: (i) the terms and expressions used herein shall have the same meanings as corresponding terms and expressions used in the Indenture; and (ii) the words “herein,” “hereof” and “hereby” and other words
of similar import used in this First Supplemental Indenture refer to this First Supplemental Indenture as a whole and not to any particular section hereof. 











 ARTICLE 2 

NOVEMBER 2019 ADDITIONAL NOTES 

Section 2.01 Creation of the November 2019 Additional Notes. In accordance with Section 2.1(a) of the Indenture, the Issuer
hereby creates the November 2019 Additional Notes as Additional Notes under the Indenture. The November 2019 Additional Notes shall be issued initially in an aggregate principal amount of $500,000,000 on the date hereof and will be issued at an
issue price of 100.00% of the principal amount thereof plus accrued and unpaid interest from September 15, 2019. Interest on the November 2019 Additional Notes shall accrue from September 15, 2019. The November 2019 Additional Notes shall
be issued as Restricted Notes. 
 Section 2.02 The Notes. The November 2019 Additional Notes initially will be issued in the
form of Global Notes as follows: 
 (a) certificate No. 144A-005 (CUSIP No. 12543D BC3 / ISIN No.
US12543DBC39) in the aggregate principal amount of $500,000,000; and 
 (b) certificate No. S-002
(CUSIP No. U17127 AM0 / ISIN No. USU17127AM09) in the aggregate principal amount of $0. 
 ARTICLE 3 

MISCELLANEOUS 
 Section 3.01
Ratification of the Indenture. 
 This First Supplemental Indenture is executed and shall be constructed as an indenture supplement to
the Indenture, and as supplemented and modified hereby, the Indenture is in all respects ratified and confirmed, and the Indenture and this First Supplemental Indenture shall be read, taken and constructed as one and the same instrument. 

Section 3.02 Real Property Mortgage. 

The Issuer shall deliver to the Collateral Agent, within 270 days after the date hereof (or such longer period as the Collateral Agent may
agree in its sole discretion): (a) counterparts of amended or amended and restated mortgages securing the Obligations with respect to the November 2019 Additional Notes and the Guarantees thereof, duly executed and delivered by the Grantor that is
the record owner of each applicable Mortgaged Property that is subject to a mortgage securing the Initial Notes and the Collateral Agent and otherwise suitable for recording and in form and substance sufficient to grant to the Collateral Agent for
the benefit of the Senior-Priority Non-ABL Loan/Notes Secured Parties a valid mortgage lien on such real property; (b) title searches confirming that there are no Liens of record in violation of the
applicable mortgage; (c) modification and date down endorsements to the existing title insurance policies; provided, however, with respect to the Mortgaged Properties located in Texas, a title search and T-38 endorsement, to the extent available, and, with respect to Mortgaged Properties in New Mexico, a title search and a modification endorsement; and (d) local counsel opinions, and any other documents
reasonably requested by the Collateral Agent in respect of the amended or amended and restated mortgages. 
 Section 3.03
Notices. 
 All notices and other communications shall be given as provided in Indenture. 

Section 3.04 Governing Law. 

THIS FIRST SUPPLEMENTAL INDENTURE AND THE NOVEMBER 2019 ADDITIONAL NOTES SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF
THE STATE OF NEW YORK. 

  
 2 












 Section 3.05 Successors. 

All agreements of the Issuer and each Guarantor in this First Supplemental Indenture and the November 2019 Additional Notes shall bind their
respective successors. All agreements of the Trustee and the Collateral Agent in this First Supplemental Indenture shall bind their respective successors. 

Section 3.06 Multiple Originals. 

The parties may sign any number of copies of this First Supplemental Indenture. Each signed copy shall be an original, but all of them together
represent the same agreement. One signed copy is enough to prove this First Supplemental Indenture. The exchange of copies of this First Supplemental Indenture and of signature pages by facsimile or PDF transmission shall constitute effective
execution and delivery of this First Supplemental Indenture as to the parties hereto and may be used in lieu of the original First Supplemental Indenture for all purposes. Signatures of the parties hereto transmitted by facsimile or PDF shall be
deemed to be their original signatures for all purposes. 
 Section 3.07 Headings. 

The headings of the Articles and Sections of this First Supplemental Indenture have been inserted for convenience of reference only, are not
intended to be considered a part hereof and shall not modify or restrict any of the terms or provisions hereof. 
 Section 3.08
Trustee Not Responsible for Recitals. 
 Neither the Trustee nor the Collateral Agent make any representation or warranty as to the
validity or sufficiency of this First Supplemental Indenture or with respect to the recitals contained herein, all of which recitals are made solely by the other parties hereto. 

[Signature page follows] 

  
 3 












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

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


 [Signature Page to First Supplemental Indenture] 












			
	FOLEY HOSPITAL CORPORATION	  	CHS TENNESSEE HOLDINGS, LLC
		
	QHG OF ENTERPRISE, INC.	  	CHS VIRGINIA HOLDINGS, LLC
		
	MCSA, L.L.C.	  	CHSPSC, LLC
		
	QHG OF SPRINGDALE, INC.	  	CLARKSVILLE HOLDINGS II, LLC 
		
	TRIAD-EL DORADO, INC.	  	CLARKSVILLE HOLDINGS, LLC
		
	BULLHEAD CITY HOSPITAL CORPORATION	  	CLEVELAND TENNESSEE HOSPITAL COMPANY, LLC
		
	ABILENE HOSPITAL, LLC	  	COLLEGE STATION HOSPITAL, L.P.
		
	ABILENE MERGER, LLC	  	COLLEGE STATION MEDICAL CENTER, LLC
		
	AFFINITY HEALTH SYSTEMS, LLC	  	COLLEGE STATION MERGER, LLC
		
	AFFINITY HOSPITAL, LLC	  	COMMUNITY HEALTH INVESTMENT COMPANY, LLC
		
	BERWICK HOSPITAL COMPANY, LLC	  	CP HOSPITAL GP, LLC
		
	BIRMINGHAM HOLDINGS II, LLC	  	CPLP, LLC
		
	BIRMINGHAM HOLDINGS, LLC	  	CRESTWOOD HEALTHCARE, L.P.
		
	BLUEFIELD HOLDINGS, LLC	  	CRESTWOOD HOSPITAL LP, LLC
		
	BLUFFTON HEALTH SYSTEM LLC	  	CRESTWOOD HOSPITAL, LLC
		
	BROWNWOOD HOSPITAL, L.P.	  	CSMC, LLC 
		
	BROWNWOOD MEDICAL CENTER, LLC	  	DESERT HOSPITAL HOLDINGS, LLC
		
	BULLHEAD CITY HOSPITAL INVESTMENT CORPORATION	  	DETAR HOSPITAL, LLC 
		
	CARLSBAD MEDICAL CENTER, LLC	  	DHFW HOLDINGS, LLC 
		
	CAROLINAS HOLDINGS, LLC	  	DUKES HEALTH SYSTEM, LLC
		
	CAROLINAS JV HOLDINGS GENERAL, LLC	  	FLORIDA HMA HOLDINGS, LLC 
		
	CAROLINAS JV HOLDINGS II, LLC	  	GADSDEN REGIONAL MEDICAL CENTER, LLC
		
	CAROLINAS JV HOLDINGS, L.P.	  	GRMC HOLDINGS, LLC
		
	CENTRAL FLORIDA HMA HOLDINGS, LLC	  	HALLMARK HEALTHCARE COMPANY, LLC 
		
	CENTRAL STATES HMA HOLDINGS, LLC	  	HEALTH MANAGEMENT ASSOCIATES, LLC 
		
	CHS RECEIVABLES FUNDING, LLC	  	HEALTH MANAGEMENT ASSOCIATES, LP 

  

					
		 	By:	 	 /s/ Kevin J. Hammons

		 		 	Name: Kevin J. Hammons
		 		 	Title:   Senior Vice President

 Acting on behalf of each of the Guarantors set forth above 

[Signature Page to First Supplemental Indenture] 












			
	HEALTH MANAGEMENT GENERAL PARTNER I, LLC	  	ORO VALLEY HOSPITAL, LLC 
		
	HEALTH MANAGEMENT GENERAL PARTNER, LLC	  	PALMER-WASILLA HEALTH SYSTEM, LLC 
		
	HMA HOSPITALS HOLDINGS, LP 	  	QHG OF BLUFFTON COMPANY, LLC
		
	HMA SERVICES GP, LLC 	  	QHG OF FORT WAYNE COMPANY, LLC 
		
	HMA-TRI HOLDINGS, LLC 	  	REGIONAL HOSPITAL OF LONGVIEW, LLC
		
	HOBBS MEDCO, LLC	  	RUSTON HOSPITAL CORPORATION 
		
	KIRKSVILLE HOSPITAL COMPANY, LLC 	  	RUSTON LOUISIANA HOSPITAL COMPANY, LLC
		
	KNOX HOSPITAL COMPANY, LLC	  	SACMC, LLC 
		
	LA PORTE HEALTH SYSTEM, LLC	  	SAN ANGELO COMMUNITY MEDICAL CENTER, LLC 
		
	LA PORTE HOSPITAL COMPANY, LLC	  	SAN ANGELO HOSPITAL, L.P.
		
	LAS CRUCES MEDICAL CENTER, LLC 	  	SAN ANGELO MEDICAL, LLC 
		
	LEA REGIONAL HOSPITAL, LLC 	  	SCRANTON HOLDINGS, LLC
		
	LONGVIEW CLINIC OPERATIONS COMPANY, LLC 	  	SCRANTON HOSPITAL COMPANY, LLC
		
	LONGVIEW MEDICAL CENTER, L.P. 	  	SCRANTON QUINCY HOLDINGS, LLC
		
	LONGVIEW MERGER, LLC 	  	SCRANTON QUINCY HOSPITAL COMPANY, LLC 
		
	LRH, LLC	  	SILOAM SPRINGS ARKANSAS HOSPITAL COMPANY, LLC
		
	LUTHERAN HEALTH NETWORK OF INDIANA, LLC	  	SILOAM SPRINGS HOLDINGS, LLC 
		
	MEDICAL CENTER OF BROWNWOOD, LLC	  	SOUTHEAST HMA HOLDINGS, LLC
		
	MISSISSIPPI HMA HOLDINGS I, LLC	  	SOUTHERN TEXAS MEDICAL CENTER, LLC
		
	MISSISSIPPI HMA HOLDINGS II, LLC 	  	SOUTHWEST FLORIDA HMA HOLDINGS, LLC
		
	MOBERLY HOSPITAL COMPANY, LLC	  	TENNESSEE HMA HOLDINGS, LP 
		
	NATCHEZ HOSPITAL COMPANY, LLC 	  	TENNYSON HOLDINGS, LLC
		
	NAVARRO HOSPITAL, L.P.	  	TRIAD HEALTHCARE, LLC
		
	NAVARRO REGIONAL, LLC 	  	TRIAD HOLDINGS III, LLC 
		
	NORTHWEST ARKANSAS HOSPITALS, LLC	  	TRIAD HOLDINGS IV, LLC
		
	NORTHWEST HOSPITAL, LLC 	  	TRIAD HOLDINGS V, LLC 
		
	NOV HOLDINGS, LLC	  	TRIAD NEVADA HOLDINGS, LLC
		
	NRH, LLC 	  	TRIAD OF ALABAMA, LLC

  

					
		 	By:	 	 /s/ Kevin J. Hammons

		 		 	Name: Kevin J. Hammons
		 		 	Title:   Senior Vice President

 Acting on behalf of each of the Guarantors set forth above 

[Signature Page to First Supplemental Indenture] 












			
	TRIAD-ARMC, LLC	  	QHG OF CLINTON COUNTY, INC.
		
	TRIAD-NAVARRO REGIONAL HOSPITAL SUBSIDIARY, LLC	  	POPLAR BLUFF REGIONAL MEDICAL CENTER, LLC 
		
	TUNKHANNOCK HOSPITAL COMPANY, LLC 	  	BILOXI H.M.A., LLC
		
	VHC MEDICAL, LLC	  	BRANDON HMA, LLC 
		
	VICKSBURG HEALTHCARE, LLC	  	CLARKSDALE HMA, LLC
		
	VICTORIA HOSPITAL, LLC 	  	JACKSON HMA, LLC
		
	VICTORIA OF TEXAS, L.P.	  	QHG OF FORREST COUNTY, INC.
		
	WARSAW HEALTH SYSTEM, LLC	  	QHG OF HATTIESBURG, INC. 
		
	WEBB HOSPITAL CORPORATION	  	RIVER OAKS HOSPITAL, LLC 
		
	WEBB HOSPITAL HOLDINGS, LLC	  	RIVER REGION MEDICAL CORPORATION 
		
	WESLEY HEALTH SYSTEM LLC 	  	ROH, LLC 
		
	WHMC, LLC	  	STATESVILLE HMA, LLC
		
	WILKES-BARRE BEHAVIORAL HOSPITAL COMPANY, LLC	  	ROSWELL HOSPITAL CORPORATION
		
	WILKES-BARRE HOLDINGS, LLC 	  	NC-DSH, LLC 
		
	WILKES-BARRE HOSPITAL COMPANY, LLC	  	CLINTON HMA, LLC
		
	WOODLAND HEIGHTS MEDICAL CENTER, LLC	  	KAY COUNTY HOSPITAL CORPORATION 
		
	WOODWARD HEALTH SYSTEM, LLC	  	KAY COUNTY OKLAHOMA HOSPITAL COMPANY, LLC 
		
	QHG GEORGIA HOLDINGS, INC.	  	MARSHALL COUNTY HMA, LLC 
		
	CITRUS HMA, LLC	  	SEMINOLE HMA, LLC 
		
	HMA SANTA ROSA MEDICAL CENTER, LLC	  	CAMPBELL COUNTY HMA, LLC 
		
	HERNANDO HMA, LLC	  	CLEVELAND HOSPITAL COMPANY, LLC
		
	HOSPITAL MANAGEMENT ASSOCIATES, LLC 	  	COCKE COUNTY HMA, LLC
		
	HOSPITAL MANAGEMENT SERVICES OF FLORIDA, LP 	  	JEFFERSON COUNTY HMA, LLC 
		
	KEY WEST HMA, LLC	  	KNOXVILLE HMA HOLDINGS, LLC 
		
	NAPLES HMA, LLC 	  	LEBANON HMA, LLC 
		
	PORT CHARLOTTE HMA, LLC 	  	METRO KNOXVILLE HMA, LLC 
		
	PUNTA GORDA HMA, LLC 	  	SHELBYVILLE HOSPITAL COMPANY, LLC 
		
	VENICE HMA, LLC 	  	TULLAHOMA HMA, LLC 
		
	FRANKFORT HEALTH PARTNER, INC. 	  	GRANBURY HOSPITAL CORPORATION 

  

					
		 	By:	 	 /s/ Kevin J. Hammons

		 		 	Name: Kevin J. Hammons
		 		 	Title:   Senior Vice President

 Acting on behalf of each of the Guarantors set forth above 

[Signature Page to First Supplemental Indenture] 












	
	LAREDO TEXAS HOSPITAL COMPANY, L.P. 
	EMPORIA HOSPITAL CORPORATION 
	FRANKLIN HOSPITAL CORPORATION 
	VIRGINIA HOSPITAL COMPANY, LLC
	OAK HILL HOSPITAL CORPORATION

  

					
		 	By:	 	 /s/ Kevin J. Hammons

		 		 	Name: Kevin J. Hammons
		 		 	Title:   Senior Vice President

 Acting on behalf of each of the Guarantors set forth above 

[Signature Page to First Supplemental Indenture] 











 
			
	TRUSTEE:
	
	REGIONS BANK
		
	By:	 	/s/ Kristine Prall
		 	Name: Kristine Prall
		 	Title:   Vice President


 [Signature Page to First Supplemental Indenture] 











 
					
	COLLATERAL AGENT:
	
	CREDIT SUISSE AG, CAYMAN ISLANDS BRANCH
			
		 	By:	 	 /s/ John D. Toronto

		 	Name: John D. Toronto
		 	Title:   Authorized Signatory
			
		 	By:	 	 /s/ Lingzi Huang

		 	Name: Lingzi Huang
		 	Title:   Authorized Signatory


 [Signature Page to First Supplemental Indenture]