Document:

EX-10.1

 Exhibit 10.1 

AMENDMENT NO. 1 (this “Amendment”) dated as of September 15, 2016, among TENET HEALTHCARE CORPORATION, a Nevada
Corporation (the “Company”), the Subsidiaries of the Company party hereto, the LC Participants and Issuers party hereto and BARCLAYS BANK PLC, as administrative agent (the “Administrative Agent”) under the Letter of
Credit Facility Agreement, dated as of March 7, 2014, among the Company, the Administrative Agent, the LC Participants and Issuers from time to time party thereto (as amended, restated, modified or supplemented from time to time, the “LC
Facility Agreement”). Capitalized terms used but not defined herein shall have the meanings assigned to such terms in the LC Facility Agreement. 

WHEREAS, Section 11.1(a)(ii) of the LC Facility Agreement provides that the Company, the Issuers and the LC Participants may enter into this
Amendment; and 
 WHEREAS, the Company, the Issuers and the LC Participants desire to amend the LC Facility Agreement on the terms set forth
herein. 
 NOW, THEREFORE, in consideration of the premises contained herein and for other good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, the parties hereto, intending to be legally bound hereby, agree as follows: 
 SECTION
1. Amendment. The Credit Parties, the Administrative Agent, the Issuers and the LC Participants hereby agree to the following amendments to the LC Facility Agreement, which shall become effective as of the Amendment No. 1
Effective Date (as defined below): 
 (a) the following definitions are hereby added in alphabetical order to Section 1.1 thereof: 

“Amendment No. 1” means that certain Amendment No. 1, dated as of September 15, 2016, among the Company, the
Subsidiaries of the Company party thereto, the LC Participants and Issuers party thereto and the Administrative Agent. 

“Amendment No. 1 Effective Date” has the meaning assigned to such term in Amendment No. 1. 

“Anti-Corruption Laws” means all laws, rules, and regulations of any jurisdiction applicable to the Company or
any of its Subsidiaries from time to time concerning or relating to bribery or corruption, including without limitation the Foreign Corrupt Practices Act of 1977, 15 U.S.C. §§ 78dd-1, et seq. 

“Anti-Money Laundering Laws” means all laws, rules, and regulations of any jurisdiction applicable to the
Company or any of its Subsidiaries from time to time concerning or relating to money laundering, including, without limitation, the Patriot Act. 

“Bail-In Action” means the exercise of any Write-Down and Conversion Powers by the applicable EEA Resolution
Authority in respect of any liability of an EEA Financial Institution. 

 “Bail-In Legislation” means with respect to any EEA Member
Country implementing Article 55 of Directive 2014/59/EU of the European Parliament and of the Council of the European Union, the implementing law for such EEA Member Country from time to time which is described in the EU Bail-In Legislation
Schedule. 
 “EEA Financial Institution” means (a) any credit institution or investment firm established in
any EEA Member Country which is subject to the supervision of an EEA Resolution Authority, (b) any entity established in an EEA Member Country which is a parent of an institution described in clause (a) of this definition, or (c) any financial
institution established in an EEA Member Country which is a subsidiary of an institution described in clauses (a) or (b) of this definition and is subject to consolidated supervision with its parent. 

“EEA Member Country” means any of the member states of the European Union, Iceland, Liechtenstein and Norway.

 “EEA Resolution Authority” means any public administrative authority or any person entrusted with public
administrative authority of any EEA Member Country (including any delegee) having responsibility for the resolution of any EEA Financial Institution. 

“EU Bail-In Legislation Schedule” means the EU Bail-In Legislation Schedule published by the Loan Market
Association (or any successor person), as in effect from time to time. 
 “Sanctioned Country” means, at any
time, a country, region or territory subject to a sanctions program administered or enforced by OFAC, the U.S. Department of State, the European Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the United
Nations Security Council. 
 “Sanctioned Person” means (a) a Person that is the target of sanctions
administered or enforced by OFAC, the U.S. Department of State, the European Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the United Nations Security Council, or (b) (i) an agency of the government of
a Sanctioned Country, (ii) an organization owned or controlled by a Sanctioned Country, or (iii) a person resident in a Sanctioned Country, to the extent subject to a sanctions program administered by OFAC, the U.S. Department of State, the European
Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the United Nations Security Council. 

“Write-Down and Conversion Powers” means with respect to any EEA Resolution Authority, the write-down and
conversion powers of such EEA Resolution Authority from time to time under the Bail-In Legislation for the applicable EEA Member Country, which write-down and conversion powers are described in the EU Bail-In Legislation Schedule. 

  
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 (b) the definition of “Applicable Margin” appearing in Section 1.1 thereof is
amended by amending and restating such definition in its entirety to read as follows: 
 “Applicable Margin” means (a) with
respect to LC Disbursements, 0.50% per annum and (b) with respect to LC Fees, 1.50% per annum. 
 (c) the definition of “Defaulting
LC Participant” appearing in Section 1.1 thereof is amended by (i) deleting the word “or” immediately prior to clause (iv) therein and (ii) inserting the words “or (v) such LC Participant becomes subject to a Bail-In
Action” immediately prior to the period appearing in such definition. 
 (d) The definition of “Eurodollar Rate”
appearing in Section 1.1 thereof is amended by adding the following sentence to the end of the definition: 
 “Notwithstanding the
foregoing, if the Eurodollar Rate as determined above for any period would be less than 0% per annum, then the Eurodollar Rate for such period shall be deemed to be 0% per annum.” 

(e) The definition of “LC Commitment” appearing in Section 1.1 thereof is amended by replacing the reference to
“Schedule I (LC Commitments)” with “Schedule 1 to Amendment No. 1”. 
 (f) the definition of “Scheduled
Termination Date” appearing in Section 1.1 thereof is hereby amended by replacing the reference to “March 7, 2017” appearing therein with “March 7, 2021”. 

(g) the definition of “Unused Commitment Fee Rate” appearing in Section 1.1 thereof is amended by amending and restating such
definition in its entirety to read as follows: 
 “Unused Commitment Fee Rate” means 0.25% per annum; provided that,
from and after the date of delivery of a Compliance Certificate with respect to the first full Fiscal Quarter commencing after the Amendment No. 1 Effective Date, such fee shall be increased to 0.375% if the Secured Debt Ratio as of the last day of
the relevant Fiscal Quarter is equal to or greater than 3.0 to 1.0 (with each change in the Unused Commitment Fee Rate to take effect on the date of delivery of the relevant Compliance Certificate). 

(h) Section 2.19(a)(i)(C) thereof is hereby amended by inserting “subject to Section 11.21 (Acknowledgment and Consent to Bail-In of
EEA Financial Institutions),” immediately prior to the word “neither” appearing therein. 
 (i) Section 4.20 thereof is
hereby amended and by amending and restating the Section in its entirety as follows: 
 “Section 4.20 OFAC.

 The Company and each of its Subsidiaries is in compliance with regulations and executive orders administered by the Office of Foreign
Assets Control of the U.S. Treasury Department (“OFAC”) or other similar economic sanctions administered or enforced by the U.S, Department of State, the European Union, any European Union Member State, Her Majesty’s Treasury
of the United Kingdom or the United Nations Security Council to the extent applicable to such Person. Neither the Company nor any of its Subsidiaries, nor to the knowledge 

  
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of the Company, any of its directors, officers or employees, is a Sanctioned Person or located, organized, or resident in any country or territory subject to comprehensive territorial sanctions,
currently Cuba, Crimea, Iran, North Korea, Sudan, or Syria. The Letters of Credit will not be used and have not been used, directly or to the knowledge of the Company, indirectly, (a) to fund any operations in or with, finance any investments or
activities in or with, or make any payments to, a Sanctioned Person or a Sanctioned Country to the extent in violation of any applicable Requirement of Law or (b) in any other manner that would result in a violation by any Person of any regulations
or executive orders administered by OFAC or other similar economic sanctions administered or enforced by the U.S. Department of State, the European Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the
United Nations Security Council.” 
 (j) Section 7.9 thereof is hereby amended and by amending and restating the Section in its
entirety as follows: 
 “Section 7.9 Application of Proceeds. 

The Company (and, to the extent distributed to them by the Company, each of its Subsidiaries) shall use the entire amount of the proceeds of
the Loans as provided in Section 4.14 (Use of Proceeds). The Company shall not request any Letter of Credit, nor use (and the Company shall procure that its Subsidiaries shall not use) the proceeds of any Letter of Credit (a) in furtherance
of an offer, payment, promise to pay, or authorization of the payment or giving of money, or anything else of value, to any Person in violation of any Anti-Corruption Laws or Anti-Money Laundering Laws, (b) for the purpose of funding, financing or
facilitating any activities, business or transaction of or with any Sanctioned Person, or in any Sanctioned Country to the extent in violation of any applicable Requirement of Law or (c) in any other manner that would result in the violation by any
Person of any regulations, executive orders, economic or financial sanctions or trade embargoes imposed, administered or enforced by OFAC or other similar economic sanctions administered or enforced by the U.S. Department of State, the European
Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the United Nations Security Council.” 

(k) Section 6.1(e) thereof is hereby amended by replacing the reference to “45 days” appearing therein with “75 days”.

 (l) the following new Section is added to Article IV thereof: 

“Section 4.21 EEA Financial Institutions. 

None of the Credit Parties is an EEA Financial Institution.” 

(m) the following new Section is added to Article VII thereof: 

“Section 4.21 Sanctions, Etc. 

The Company will maintain in effect and enforce policies and procedures designed to ensure compliance by the Company and its Subsidiaries and
their respective directors, 

  
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officers and employees with Anti-Corruption Laws, Anti-Money Laundering Laws and regulations and executive orders administered by OFAC or other similar economic sanctions administered or enforced
by the U.S. Department of State, the European Union, any European Union Member State, Her Majesty’s Treasury of the United Kingdom or the United Nations Security Council to the extent applicable to such Person.” 

(n) the following new Section is added to Article XI thereof: 

“Section 11.21 Acknowledgement and Consent to Bail-In of EEA Financial Institutions. 

Notwithstanding anything to the contrary in this LC Facility Agreement or in any other agreement, arrangement or understanding among any such
parties, each party hereto acknowledges that any liability of any LC Participant or Issuer that is an EEA Financial Institution arising under this LC Facility Agreement, to the extent such liability is unsecured, may be subject to the write-down and
conversion powers of an EEA Resolution Authority and agrees and consents to, and acknowledges and agrees to be bound by: 
 (a) the
application of any Write-Down and Conversion Powers by an EEA Resolution Authority to any such liabilities arising hereunder which may be payable to it by any LC Participant or Issuer that is an EEA Financial Institution; and 

(b) the effects of any Bail-in Action on any such liability, including, if applicable: 

(i) a reduction in full or in part or cancellation of any such liability; 

(ii) a conversion of all, or a portion of, such liability into shares or other instruments of ownership in such EEA Financial Institution, its
parent undertaking, or a bridge institution that may be issued to it or otherwise conferred on it, and that such shares or other instruments of ownership will be accepted by it in lieu of any rights with respect to any such liability under this LC
Facility Agreement or other LC Facility Document; or 
 (iii) the variation of the terms of such liability in connection with the exercise of
the write-down and conversion powers of any EEA Resolution Authority.” 
 SECTION 2. Representations and
Warranties. The Company hereby represents and warrants that, both immediately before and immediately after giving effect to this Amendment: 

(a) The representations and warranties set forth in the LC Facility Documents are true and correct in all material respects, with the same
effect as though made on and as of such times, except to the extent any such representation and warranty expressly relates to an earlier date or period (in which case such representation and warranty shall be true and correct in all material
respects as of such earlier date or for such earlier period, as the case may be); and 

  
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 (b) no Default or Event of Default exists and is continuing on and as of such times. 

SECTION 3. Effectiveness. Section 1 of this Amendment shall become effective on the date (such date, if any,
the “Amendment No. 1 Effective Date”) that the following conditions have been satisfied: 
 (a) the Administrative Agent (or
its counsel) shall have received from the Company, each Issuer and each LC Participant either (i) a counterpart of this Amendment signed on behalf of such party or (ii) written evidence satisfactory to the Administrative Agent (which may include
telecopy or electronic transmission of a signed signature page of this Amendment) that such party has signed a counterpart of this Amendment; 

(b) the Administrative Agent shall have received an opinion of (i) Gibson, Dunn & Crutcher LLP, New York counsel to the Credit Parties,
(ii) Nevada counsel to the Credit Parties and (iii) the Deputy General Counsel of the Company, in each case, addressed to the Administrative Agent, the Issuers and the LC Participants, and in form reasonably satisfactory to the Administrative Agent;

 (c) the Administrative Agent shall have received a certificate of the Secretary or an Assistant Secretary of each Credit Party certifying
(i) the names and true signatures of each officer of such Credit Party that has been authorized, as of the date of such certification, to execute and deliver this Amendment or other document required hereunder to be executed and delivered by or on
behalf of such Credit Party and (ii) (x) the by-laws (or equivalent Constituent Document) of such Credit Party as in effect on the date of such certification or (y) that there have been no changes in the by-laws (or equivalent Constituent Document)
of such Credit Party from the by-laws (or equivalent Constituent Document) of such Credit Party delivered pursuant to Section 3.1(a)(viii) of the LC Facility Agreement and (C) that there have been no changes in the certificate of incorporation (or
equivalent Constituent Document) of such Credit Party from the certificate of incorporation (or equivalent Constituent Document) delivered pursuant to Section 3.1(a)(vii) of the LC Facility Agreement; 

(d) the Administrative Agent shall have received a short form certificate, certified as of a recent date by the Secretary of State of the
state of organization of each Credit Party, attesting to the good standing of each such Credit Party; and 
 (e) the Administrative Agent
shall have received, for the account of each LC Participant that has consented to this Amendment prior to 4:00 p.m., New York City time, on September 15, 2016 a fee equal to 0.25% of the aggregate principal amount of such LC Participant’s LC
Commitment and the Company shall have paid to Barclays Bank PLC such fees as have been separately agreed in writing prior to the date hereof. 

SECTION 4. Certain Consequences of Effectiveness; Reaffirmation. On and after the Amendment No. 1 Effective Date,
references in the LC Facility Agreement to this “Agreement”, “hereunder”, “hereof”, “herein” or words of similar import and references in the LC Facility Documents to the
“Agreement”, “LC Facility Agreement”, “thereunder,” “thereof”, “therein” or words of similar import shall mean, and refer to, the LC Facility Agreement, as

  
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amended by this Amendment. Except as expressly set forth herein, this Amendment shall not constitute an amendment or waiver of any provision of the LC Facility Agreement or any other LC
Facility Document all of which shall remain in full force and effect. Each Credit Party hereby acknowledges and agrees that, following the Amendment No. 1 Effective Date, it shall continue to be bound by the LC Facility Documents to which it is
party (in the case of the LC Facility Agreement, as amended by this Amendment) and each of the Credit Parties hereby (i) consents to the execution, delivery and performance of this Amendment and each of the transactions contemplated hereby, (ii)
acknowledges and reaffirms its respective guarantees, pledges, grants of security interests and other obligations, as applicable, under and subject to the terms of the LC Facility Documents, (iii) acknowledges and agrees that, notwithstanding the
effectiveness of this Amendment, the Collateral Documents, the Collateral Trust Joinder – Additional Secured Debt, the Additional Secured Debt Designation and the Guaranty (and any amendments thereto) shall continue in full force and effect and
(iv) acknowledges and agrees that all references in the Collateral Documents, the Collateral Trust Joinder – Additional Secured Debt, the Additional Secured Debt Designation and the Guaranty (and any amendments thereto) to the
“Agreement”, “LC Facility Agreement”, “thereunder,” “thereof”, “therein” or words of similar import shall be deemed to mean a reference to the LC Facility Agreement
as amended by this Amendment. Furthermore, each of the Credit Parties acknowledges and agrees that it is the intention of such party (i) that the Collateral Documents, the Collateral Trust Joinder – Additional Secured Debt and the Additional
Secured Debt Designation (and any amendments thereto) and the Liens granted thereby shall not be affected, impaired or discharged hereby or by the transactions contemplated under this Amendment and (ii) the Liens granted by the Collateral Documents,
the Collateral Trust Joinder – Additional Secured Debt and the Additional Secured Debt Designation (including any amendments thereto) shall continue unimpaired and with the same priority to secure repayment of all Obligations, whether
heretofore or hereafter incurred. For the avoidance of doubt, (i) to the extent an LC Participant under the LC Facility Agreement as in effect upon the Amendment No. 1 Effective Date was not listed on Schedule I to the LC Facility Agreement but is
listed on Schedule I to Amendment No. 1, such LC Participant’s LC Commitment will begin as of the Amendment No. 1 Effective Date and (ii) to the extent an LC Participant under the LC Facility Agreement as in effect prior to the Amendment
No. 1 Effective Date is not listed on Schedule I to Amendment No. 1, such LC Participant’s LC Commitment will terminate as of the Amendment No. 1 Effective Date.

SECTION 5. Incorporation by Reference. This Amendment shall constitute a “LC Facility Document” for
purposes of the LC Facility Agreement. The provisions of Section 11.11, 11.12, 11.13 and 11.17 of the LC Facility Agreement are incorporated herein mutatis mutandis. 

[signature pages follow] 

  
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 IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be duly executed by their
respective authorized officers as of the day and year first written above. 
  

			
	TENET HEALTHCARE CORPORATION
		
	By:	 	 /s/ James E. Snyder III

		 	 Name: James E. Snyder III

Title: Assistant Treasurer

  

			
	THE SUBSIDIARIES LISTED ON SCHEDULE II
		
	By:	 	 /s/ James E. Snyder III

		 	 Name: James E. Snyder III

Title: Assistant Treasurer

  

			
	THE SUBSIDIARIES LISTED ON SCHEDULE III
		
	By:	 	 /s/ William G. Morrison

		 	 Name: William G. Morrison

Title: Treasurer

 
			
	 BARCLAYS BANK PLC, as Administrative
Agent, LC Participant and Issuer

		
	By:	 	 /s/ Christine Aharonian

		 	 Name: Christine Aharonian

Title: Vice President

 
			
	GOLDMAN SACHS LENDING PARTNERS
LLC, as LC Participant
		
	By:	 	 /s/ Annie Carr

		 	 Name: Annie Carr
 Title: Authorized
Signatory

 
			
	 SUNTRUST BANK, as LC Participant

		
	By:	 	 /s/ Jared Cohen

		 	 Name: Jared Cohen
 Title: Vice
President

 
			
	 CITIBANK, N.A., as LC Participant and Issuer

		
	By:	 	 /s/ Laura Fogarty

		 	 Name: Laura Fogarty
 Title: Vice
President (Managing Director)

 
			
	WELLS FARGO, NATIONAL ASSOCIATION, as
LC Participant
		
	By:	 	 /s/ Kirk Tesch

		 	 Name: Kirk Tesch

Title: Managing Director

 
			
	BANK OF AMERICA, N.A., as LC Participant and
Issuer
		
	By:	 	 /s/ Sujay Maiya

		 	 Name: Sujay Maiya

Title: Vice President

 
			
	JPMORGAN CHASE BANK, N.A., as LC Participant
		
	By:	 	 /s/ Vanessa Chiu

		 	 Name: Vanessa Chiu

Title: Executive Director

 SCHEDULE I 

LC COMMITMENTS 
  

					
	 LC Participant
	  	LC Commitment	 
	 Barclays Bank PLC
	  	$	30,000,000	  
	 Bank of America, N.A.
	  	$	30,000,000	  
	 SunTrust Bank
	  	$	30,000,000	  
	 Wells Fargo Bank, N.A.
	  	$	30,000,000	  
	 Citibank, N.A.
	  	$	20,000,000	  
	 Goldman Sachs Lending Partners LLC
	  	$	20,000,000	  
	 JPMorgan Chase Bank, N.A.
	  	$	20,000,000	  
		  	  
	  
	 
	 Total
	  	$	180,000,000	  
		  	  
	  
	 

 SCHEDULE II 
  

	
	 American Medical (Central), Inc.

	 AMI Information Systems Group, Inc.

	 Amisub (Heights), Inc.

	 Amisub (Hilton Head), Inc.

	 Amisub (SFH), Inc.

	 Amisub (Twelve Oaks), Inc.

	 Amisub of North Carolina, Inc.

	 Amisub of South Carolina, Inc.

	 Amisub of Texas, Inc.

	 Anaheim MRI Holding, Inc. (formerly known as USC University Hospital, Inc. and formerly known as
Tenet 1500 San Pablo, Inc.)

	 BBH BMC, LLC

	 Brookwood Baptist Health 1, LLC

	 Brookwood Health Services, Inc.

	 CGH Hospital, Ltd.

	 Coastal Carolina Medical Center, Inc.

	 Community Hospital of Los Gatos, Inc.

	 Coral Gables Hospital, Inc.

	 Cypress Fairbanks Medical Center, Inc.

	 Delray Medical Center, Inc.

	 Desert Regional Medical Center, Inc. (f/k/a Tenet HealthSystem Desert, Inc.)

	 Des Peres Hospital, Inc. (f/k/a Tenet HealthSystem DI, Inc.)

	 Doctors Hospital of Manteca, Inc.

	 Doctors Medical Center of Modesto, Inc.

	 East Cooper Community Hospital, Inc.

	 FMC Medical, Inc.

	 Fountain Valley Regional Hospital and Medical Center

	 Frye Regional Medical Center, Inc.

	 Good Samaritan Medical Center, Inc. (f/k/a Tenet Good Samaritan, Inc.)

	 Hialeah Hospital, Inc. (f/k/a Tenet Hialeah HealthSystem, Inc.)

	 Hilton Head Health System, L.P.

	 JFK Memorial Hospital, Inc.

	 Lakewood Regional Medical Center, Inc.

	 Lifemark Hospitals, Inc.

	 Lifemark Hospitals of Florida, Inc.

	 Los Alamitos Medical Center, Inc.

	 New Medical Horizons II, Ltd.

	 North Shore Medical Center, Inc. (f/k/a Tenet HealthSystem North Shore, Inc.)

	
	 OrNda Hospital Corporation

	 Palm Beach Gardens Community Hospital, Inc.

	 Placentia-Linda Hospital, Inc.

	 Saint Francis Hospital – Bartlett, Inc. (f/k/a Tenet HealthSystem Bartlett,
Inc.)

	 St. Mary’s Medical Center, Inc. (f/k/a Tenet St. Mary’s, Inc.)

	 San Ramon Regional Medical Center, LLC

	 Sierra Vista Hospital, Inc.

	 SRRMC Management, Inc.

	 Tenet California, Inc.

	 Tenet Florida, Inc.

	 Tenet Frisco, Ltd.

	 Healthcare Network CFMC, Inc. (f/k/a Tenet HealthSystem CFMC, Inc.)

	 Tenet HealthSystem Hahnemann, L.L.C.

	 HealthCorp Network, Inc. (f/k/a Tenet HealthSystem HealthCorp)

	 Healthcare Network Holdings, Inc. (f/k/a Tenet HealthSystem Holdings, Inc.)

	 Sylvan Grove Hospital, Inc. (f/k/a Tenet HealthSystem SGH, Inc.)

	 Tenet HealthSystem Medical, Inc.

	 Tenet HealthSystem Philadelphia, Inc.

	 SLH Vista, Inc. (f/k/a Tenet HealthSystem SL, Inc.)

	 Spalding Regional Medical Center, Inc.

	 Tenet HealthSystem St. Christopher’s Hospital for Children, L.L.C.

	 Tenet Physician Services – Hilton Head, Inc.

	 Health Services Network Hospitals, Inc. (f/k/a Tenet Hospitals, Inc.)

	 Tenet Hospitals Limited

	 Healthcare Network Louisiana, Inc. (f/k/a Tenet Louisiana, Inc.)

	 Healthcare Network Missouri, Inc. (f/k/a Tenet Missouri, Inc.)

	 Healthcare Network Texas, Inc. (f/k/a Tenet Texas, Inc.)

	 Health Services Network Texas, Inc. (f/k/a Tenetsub Texas, Inc.)

	 TH Healthcare, Ltd.

	 Twin Cities Community Hospital, Inc.

	 West Boca Medical Center, Inc.

	 Hospital Development of West Phoenix, Inc.

	 VHS Acquisition Corporation

	 VHS Acquisition Subsidiary Number 1, Inc.

	 VHS Acquisition Subsidiary Number 7, Inc.

	 VHS Acquisition Subsidiary Number 9, Inc.

	 VHS Children’s Hospital of Michigan, Inc.

	 VHS Detroit Receiving Hospital, Inc.

	 VHS Harper-Hutzel Hospital, Inc.

	 VHS Huron Valley-Sinai Hospital, Inc.

	
	 VHS of Arrowhead, Inc.

	 VHS of Illinois, Inc.

	 VHS Rehabilitation Institute of Michigan, Inc.

	 VHS San Antonio Partners, LLC

	 VHS Sinai-Grace Hospital, Inc.

	 VHS West Suburban Medical Center, Inc.

	 VHS Westlake Hospital, Inc.

	 VHS of Phoenix, Inc.

	 VHS Acquisition Subsidiary Number 3, Inc.

	 Vanguard Health Financial Company, LLC

	 Vanguard Health Holding Company I, LLC

	 Vanguard Health Holding Company II, LLC

	 Vanguard Health Management, Inc.

	 Vanguard Health Systems, Inc.

	 VHS of Michigan, Inc.

 SCHEDULE III 
  

	
	 Atlanta Medical Center, Inc.

	 North Fulton Medical Center, Inc.Guarantee Agreement for 2.625% Notes due 2026

 Exhibit 4.1 

GUARANTEE, dated as of September 16, 2016 (as amended from time to time, this “Guarantee”), made by Philip Morris USA
Inc., a Virginia corporation (the “Guarantor”), in favor of Deutsche Bank Trust Company Americas, as trustee (“Trustee”) for the registered holders (the “Holders”) of the 2.625% Notes due 2026
(collectively, the “Debt Securities”) of Altria Group, Inc., a Virginia corporation (the “Issuer”). 

WITNESSETH: 
 SECTION 1.
Guarantee. (a) The Guarantor hereby unconditionally guarantees the punctual payment when due, whether at stated maturity, by acceleration or otherwise, of the principal of, premium, if any, and interest on the Debt Securities (the
“Obligations”), according to the terms of the Debt Securities and as more fully described in the Indenture (as amended, modified or otherwise supplemented from time to time, the “Indenture”), dated as of
November 4, 2008, among the Issuer, the Guarantor and the Trustee, and any other amounts payable by the Guarantor under the Indenture. 

(b) It is the intention of the Guarantor that this Guarantee not constitute a fraudulent transfer or conveyance for purposes of Bankruptcy
Law, the Uniform Fraudulent Conveyance Act, the Uniform Fraudulent Transfer Act or any similar federal or state law to the extent applicable to this Guarantee. To effectuate the foregoing intention, the amount guaranteed by the Guarantor under this
Guarantee shall be limited to the maximum amount as will, after giving effect to such maximum amount and all other contingent and fixed liabilities of the Guarantor that are relevant under such laws, result in the Obligations of the Guarantor under
this Guarantee not constituting a fraudulent transfer or conveyance. For purposes hereof, “Bankruptcy Law” means Title 11, U.S. Code, or any similar federal or state law for the relief of debtors. 

SECTION 2. Guarantee Absolute. The Guarantor guarantees that the Obligations will be paid strictly in accordance with the terms of the
Indenture, regardless of any law, regulation or order now or hereafter in effect in any jurisdiction affecting any of such terms or the rights of Holders of the Debt Securities with respect thereto. The liability of the Guarantor under this
Guarantee shall be absolute and unconditional irrespective of: 
 (i) any lack of validity, enforceability or genuineness of
any provision of the Indenture, the Debt Securities or any other agreement or instrument relating thereto; 
 (ii) any change
in the time, manner or place of payment of, or in any other term of, all or any of the Obligations, or any other amendment or waiver of or any consent to departure from the Indenture; 

(iii) any exchange, release or non-perfection of any collateral, or any release or amendment or waiver of or consent to
departure from any other guarantee, for all or any of the Obligations; or 
 (iv) any other circumstance that might otherwise
constitute a defense available to, or a discharge of, the Issuer or a guarantor. 

 SECTION 3. Subordination. The Guarantor covenants and agrees that its obligation to make
payments of the Obligations hereunder constitutes an unsecured obligation of the Guarantor ranking (a) pari passu with all existing and future senior indebtedness of the Guarantor and (b) senior in right of payment to all existing
and future subordinated indebtedness of the Guarantor. 
 SECTION 4. Waiver; Subrogation. (a) The Guarantor hereby waives
promptness, diligence, notice of acceptance and any other notice with respect to this Guarantee and any requirement that the Trustee, or the Holders of any Debt Securities protect, secure, perfect or insure any security interest or lien or any
property subject thereto or exhaust any right or take any action against the Issuer or any other Person or any collateral. 
 (b) The
Guarantor hereby irrevocably waives any claims or other rights that it may now or hereafter acquire against the Issuer that arise from the existence, payment, performance or enforcement of the Guarantor’s obligations under this Guarantee or the
Indenture, including, without limitation, any right of subrogation, reimbursement, exoneration, contribution or indemnification and any right to participate in any claim or remedy of the Trustee, or the Holders of any Debt Securities against the
Issuer or any collateral, whether or not such claim, remedy or right arises in equity or under contract, statute or common law, including, without limitation, the right to take or receive from the Issuer, directly or indirectly, in cash or other
property or by set-off or in any other manner, payment or security on account of such claim, remedy or right. If any amount shall be paid to the Guarantor in violation of the preceding sentence at any time prior to the cash payment in full of the
Obligations and all other amounts payable under this Guarantee, such amount shall be held in trust for the benefit of the Trustee and the Holders of any Debt Securities and shall forthwith be paid to the Trustee, to be credited and applied to the
Obligations and all other amounts payable under this Guarantee, whether matured or unmatured, in accordance with the terms of the Indenture and this Guarantee, or be held as collateral for any Obligations or other amounts payable under this
Guarantee thereafter arising. The Guarantor acknowledges that it will receive direct and indirect benefits from the financing arrangements contemplated by the Indenture and this Guarantee and that the waiver set forth in this Section 4 is
knowingly made in contemplation of such benefits. 
 SECTION 5. No Waiver; Remedies. No failure on the part of the Trustee or any
Holder of the Debt Securities to exercise, and no delay in exercising, any right hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any right hereunder preclude any other or further exercise thereof or the
exercise of any other right. The remedies herein provided are cumulative and not exclusive of any remedies provided by law. 
 SECTION 6.
Continuing Guarantee; Transfer of Interest. This Guarantee is a continuing guarantee and shall (a) remain in full force and effect until the earliest to occur of (i) the date, if any, on which the Guarantor shall consolidate with or
merge into the Issuer or any successor thereto, (ii) the date, if any, on which the Issuer or any successor thereto shall consolidate with or merge into the Guarantor, (iii) payment in full of the Obligations, and (iv) the rating of
the Issuer’s long term senior unsecured debt by Standard & Poor’s of A or higher, (b) be binding upon the Guarantor, its successors and assigns, and (c) inure to the benefit of and be

  
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enforceable by any Holder of Debt Securities, the Trustee, and by their respective successors, transferees, and assigns. 

SECTION 7. Reinstatement. This Guarantee shall continue to be effective or be reinstated, as the case may be, if at any time any
payment of any of the Obligations is rescinded or must otherwise be returned by any Holder of the Debt Securities or the Trustee upon the insolvency, bankruptcy or reorganization of the Issuer or otherwise, all as though such payment had not been
made. 
 SECTION 8. Amendment. The Guarantor may amend this Guarantee at any time for any purpose without the consent of the Trustee
or any Holder of the Debt Securities; provided, however, that if such amendment adversely affects (a) the rights of the Trustee or (b) any Holder of the Debt Securities, the prior written consent of the Trustee (in the case of (b),
acting at the written direction of the Holders of more than 50% in aggregate principal amount of Debt Securities) shall be required. 

SECTION 9. Governing Law. This Guarantee shall be governed by, and construed in accordance with the laws of the State of New York. 

[Signature Page Follows] 

  
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 IN WITNESS WHEREOF, the Guarantor has caused this Guarantee to be duly executed and delivered by
its officer thereunto duly authorized as of the date first written above. 
  

					
	PHILIP MORRIS USA INC.
		
	By:	 	/s/ Clifford B. Fleet
		 	Name:	 	Clifford B. Fleet
		 	Title:	 	President and Chief Executive Officer

  
 Signature Page to
Guarantee Agreement

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