Document:

VANGUARD HEALTH SYSTEMS, INC.

EXHIBIT 4.1

SUPPLEMENTAL INDENTURE

            SEVENTH SUPPLEMENTAL INDENTURE (this “Supplemental Senior Subordinated Indenture”), dated as of  November 3, 2008, among  VHS
Acquisition Subsidiary Number 12, Inc., a Delaware corporation ( the “New Guarantor”) and a subsidiary of Vanguard Health Holding Company II, LLC, a Delaware limited liability company (“VHS Holdco II”), Vanguard Holding Company
II, Inc., a Delaware corporation and a wholly owned subsidiary of VHS Holdco II (together with VHS Holdco II, the “Issuers”), Vanguard Health Holding Company I, LLC, Vanguard Health Systems, Inc. and U.S. Bank National Association, as trustee under
the Senior Subordinated Indenture referred to below (the “Trustee”).

WITNESSETH

            WHEREAS, the Issuers and the existing Guarantors have heretofore executed and delivered to the Trustee an indenture (as amended, supplemented or otherwise
modified, the “Senior Subordinated Indenture”), dated as of September 23, 2004 providing for the issuance of 9% Senior Subordinated Notes due 2014 (the “Senior Subordinated Notes”);

            WHEREAS, Section 4.16 of the Senior Subordinated Indenture provides that under certain circumstances the New Guarantor shall execute and deliver to the Trustee
a supplemental indenture pursuant to which the New Guarantor shall unconditionally guarantee all of the Issuers’ Obligations under the Senior Subordinated Notes and the Senior Subordinated Indenture on the terms and conditions set forth herein (the
“Note Guarantee”); and

            WHEREAS, pursuant to Section 9.01 of the Senior Subordinated Indenture, the Trustee and the Issuers are authorized to execute and deliver this Supplemental
Senior Subordinated Indenture.

            NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt of which is hereby acknowledged, the New
Guarantor, the Issuers and the Trustee mutually covenant and agree for the equal and ratable benefit of the Holders of the Senior Subordinated Notes as follows:

            1.         DEFINED TERMS.  Defined terms used herein without definition shall have the meanings assigned to them
in the Senior Subordinated Indenture.

            2.         AGREEMENT TO GUARANTEE.  The New Guarantor hereby agree, jointly and severally with all existing
Guarantors (if any), to provide an unconditional Guarantee on the terms and subject to the conditions set forth in Article 12 of the Senior Subordinated Indenture and to be bound by all other applicable provisions of the Senior Subordinated Indenture and the Senior
Subordinated Notes and to perform all of the obligations and agreements of a Guarantor under the Senior Subordinated

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Indenture.  The Guarantee of the New Guarantor shall be subordinated to Senior Debt as provided in the Senior Subordinated Note Indenture

            3.         NO RECOURSE AGAINST OTHERS.  No past, present or future director, manager, officer, employee,
incorporator, stockholder or member of the Issuers, any parent entity of the Issuers or any Subsidiary, as such, will have any liability for any obligations of the Issuers or the Guarantors under the Senior Subordinated Notes, this Senior Subordinated Indenture, the
Note Guarantees or for any claim based on, in respect of, or by reason of, such obligations or their creation.  Each Holder of Senior Subordinated Notes by accepting a Senior Subordinated Note waives and releases all such liability.  The waiver and release
are part of the consideration for issuance of the Senior Subordinated Notes.  The waiver may not be effective to waive liabilities under the federal securities laws.

            4.         NOTICES.  All notices or other communications to the New Guarantor shall be given as provided in
Section 14.02 of the Senior Subordinated Indenture.

            5.         RATIFICATION OF INDENTURE; SUPPLEMENTAL INDENTURES PART OF INDENTURE.  Except as expressly amended
hereby, the Senior Subordinated 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 Senior Subordinated Indenture shall form a part of the Senior
Subordinated Indenture for all purposes, and every holder of Senior Subordinated Notes heretofore or hereafter authenticated and delivered shall be bound hereby.

            6.         GOVERNING LAW.  THIS INDENTURE, THE NOTES AND THE SENIOR SUBORDINATED NOTE GUARANTEES SHALL BE GOVERNED
BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK.

            7.         COUNTERPARTS.  The parties may sign any number of copies of this Supplemental Senior Subordinated
Indenture.  Each signed copy shall be an original, but all of them together represent the same agreement.

            8.         EFFECT OF HEADINGS.  The Section headings herein are for convenience only and shall not affect the
construction hereof.

            9.         TRUSTEE MAKES NO REPRESENTATION.  The Trustee makes no representation as to the validity or sufficiency
of this Supplemental Indenture.

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

Dated: November 3, 2008

                                                                       
VHS ACQUISITION SUBSIDIARY

                                                                       
NUMBER 12, INC.

                                                                       
By: /s/ James H. Spalding                     

                                                                       
Name: James H. Spalding

                                                                       
Title: Senior Vice President

                                                                       
VANGUARD HEALTH HOLDING

                                                                       
COMPANY II, LLC

                                                                       
By: /s/ James H. Spalding                     

                                                                       
Name: James H. Spalding

                                                                       
Title: Senior Vice President

                                                                       
VANGUARD HOLDING COMPANY II,

                                                                       
INC.

                                                                       
By: /s/ James H. Spalding                     

                                                                       
Name: James H. Spalding

                                                                       
Title: Senior Vice President

                                                                       
VANGUARD HEALTH HOLDING

                                                                       
COMPANY I, LLC

                                                                       
By: /s/ James H. Spalding                     

                                                                       
Name: James H. Spalding

                                                                       
Title: Senior Vice President

                                                                       
VANGUARD HEALTH SYSTEMS, INC.

                                                                       
By: /s/ James H. Spalding                     

                                                                       
Name: James H. Spalding

                                                                       
Title: Senior Vice President

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U.S. BANK NATIONAL ASSOCIATION

                                                                       
as Trustee

                       
                                               
By: /s/ Richard Prokosch                     

                                                                       
Name: Richard Prokosch

                                                                       
Title: Vice President

4VANGUARD HEALTH SYSTEMS, INC.

EXHIBIT 10.1

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

SECTION A: CONTRACT

	

 1. AMENDMENT NUMBER:

     2

		
2.  CONTRACT NO.:

      YH09-0001-07

		
3.  EFFECTIVE DATE OF CONTRACT:

      January 15, 2009

		
4.  PROGRAM:

      DHCM - ACUTE

	

 5. CONTRACTOR’S NAME AND ADDRESS:

VHS Phoenix Health Plan, LLC

 7878 N. 16th St., Suite 105

 Phoenix, Arizona  85020

	

 6. PURPOSE OF AMENDMENT:  To amend Section D.

	
7.

	
 

	
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
A.

		
Added to Paragraph 58, Coordination of Benefits, the following language to the end of the paragraph:

AHCCCS has developed a process and agreement with Blue Cross Blue Shield of Arizona (BCBSAZ) to receive both historic and current BCBSAZ coverage data

Based on this information, AHCCCS will be submitting claims on behalf of AHCCCS Contractors for services reimbursed for dates of services 1/15/06 through 3/31/08. From the monies recovered, AHCCCS will disburse 50% to the
Contractor and 50% to the Agency for recoveries of non-TWG, non-PPC, non-Reinsurance related claims. For these claims, AHCCCS will withhold 12% of the disbursement to the Contractor to compensate the vendor recovering the funds. AHCCCS will retain 100% of any BCBSAZ
recoveries related to PPC, TWG and Reinsurance-related claims The Contractor is restricted from recouping any funds for BCBSAZ liability for the period of 1/15/06- 3/31/08. However, the Contractor is responsible for coordination of benefits from 4/1/08
forward.

	
 

	
By signing this contract, the Contractor is agreeing to the terms of the contract.

	
 

	
NOTE:  Please sign and date all copies and then return one executed original to:    
              Mark Held

                                                                                                                                
Sr. Procurement Specialist

                                                                                                                                
AHCCCS Contracts

                                                                                                                                
701 E. Jefferson St., MD 5700

                                                                                                                                
Phoenix, AZ  85034

	
 

	
8.  EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

	
 

	
 

	
 

	
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

	
9.  SIGNATURE OF AUTHORIZED REPRESENTATIVE:

	
 

	
10.  SIGNATURE OF AHCCCSA CONTRACTING OFFICER:

	
     /a/ Nancy Novick

	
 

	
       /s/ Michael Veit

	
 

	
 

	
 

	
TYPED NAME:        NANCY NOVICK

	
 

	
MICHAEL VEIT

	
TITLE:                    CHIEF EXECUTIVE OFFICER

	
 

	
CONTRACTS & PURCHASING ADMINISTRATOR

	
DATE:                     1/16/09

	
 

	
DATE:     JAN 12, 2009

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