Joinder Agreement No. 6, dated as of March 13, 2018, by and among HCA Inc., as borrower, the guarantors party thereto, Bank of America, N.A., as administrative agent and collateral agent, and the lenders party thereto

Exhibit 4.1

Execution Version

TRANCHE B-10 TERM LOAN

JOINDER AGREEMENT NO. 6

JOINDER AGREEMENT NO. 6, dated as of March 13, 2018 (this “Agreement”), by and among Bank of America, N.A. (the “Tranche B-10 Funding Loan Lender”), each Tranche B-10 Converting Loan Lender (as defined below), HCA INC., a Delaware corporation (the “Borrower”) and BANK OF AMERICA, N.A., as Administrative Agent and as Collateral Agent.

RECITALS:

WHEREAS, reference is hereby made to the Credit Agreement, dated as of November 17, 2006, as amended and restated as of May 4, 2011, as further amended and restated as of February 26, 2014, as further supplemented as of June 10, 2015, March 18, 2016, August 15, 2016, February 15, 2017 and March 20, 2017 and as further amended and restated as of June 28, 2017 (as further amended, restated, supplemented or otherwise modified from time to time, the “Credit Agreement”), among the Borrower, the Lenders party thereto, Bank of America, N.A., as Administrative Agent, Collateral Agent, Swingline Lender and Letter of Credit Issuer and the other parties named therein (capitalized terms used but not defined herein having the meaning provided in the Credit Agreement);

WHEREAS, subject to the terms and conditions of the Credit Agreement, the Borrower may establish New Term Loan Commitments by, among other things, entering into one or more Joinder Agreements with New Term Loan Lenders;

WHEREAS, the Borrower desires to establish a Series of New Term Loans in an aggregate initial principal amount equal to $1,500,000,000 pursuant to this Agreement which shall be titled the “Tranche B-10 Term Loans”;

WHEREAS, the Tranche B-10 Term Loans constitute Ratio First Lien Indebtedness under the Credit Agreement; and

WHEREAS, Bank of America, N.A., Citigroup Global Markets Inc., Goldman Sachs Bank USA, JPMorgan Chase Bank, N.A. and Wells Fargo Securities, LLC are acting as joint lead arrangers and joint bookrunners for the Tranche B-10 Term Loans.

NOW, THEREFORE, in consideration of the premises and agreements, provisions and covenants herein contained, the parties hereto agree as follows:

The Tranche B-10 Funding Loan Lender hereby agrees to commit to provide its New Term Loan Commitment with respect to the Tranche B-10 Term Loans (its “Tranche B-10 Term Loan Commitment”), as set forth on Schedule A annexed hereto, on the terms and subject to the conditions set forth below. Each Tranche B-8 Term Loan Lender that has executed a counterpart of this Agreement in its capacity as such (each a “Tranche B-10 Converting Loan Lender” and together with the Tranche B-10 Funding Loan Lender, the “Tranche B-10 Loan Lenders”) indicating its willingness to convert Tranche B-8 Term Loans to Tranche B-10 Term Loans, hereby agrees to have the portion of such Tranche B-8 Term Loans so converted in accordance herewith (after giving effect to any reduction as contemplated by the signature pages

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hereto) (as to such Tranche B-10 Converting Loan Lender, its “Converted Tranche B-8 Term Loan”) converted to Tranche B-10 Term Loans on the terms and subject to the conditions set forth below.

Each Tranche B-10 Loan Lender (i) confirms that it has received a copy of the Credit Agreement and the other Credit Documents and the exhibits thereto, together with copies of the financial statements referred to therein and such other documents and information as it has deemed appropriate to make its own credit analysis and decision to enter into this Agreement; (ii) agrees that it will, independently and without reliance upon the Administrative Agent or any other Lender or Agent and based on such documents and information as it shall deem appropriate at the time, continue to make its own credit decisions in taking or not taking action under the Credit Agreement; (iii) appoints and authorizes the Administrative Agent to take such action as agent on its behalf and to exercise such powers under the Credit Agreement and the other Credit Documents as are delegated to the Administrative Agent by the terms thereof, together with such powers as are reasonably incidental thereto; and (iv) agrees that it will perform in accordance with their terms all of the obligations which by the terms of the Credit Agreement are required to be performed by it as a Tranche B-10 Loan Lender.

The Tranche B-10 Loan Lender hereby agrees to make its respective Commitment on the following terms and conditions:

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Notwithstanding the foregoing, the Borrower shall repay all outstanding Tranche B-10 Term Loans on March 13, 2025 (or, if such day is not a Business Day, the immediately preceding Business Day) (the “Tranche B-10 Term Loan Maturity Date”).

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For purposes of the foregoing:

“Repricing Transaction” shall mean the repayment, refinancing or replacement of all or a portion of the Tranche B-10 Term Loans with proceeds from the incurrence by any Credit Party of any long-term bank debt financing incurred for the primary purpose of repaying, refinancing or replacing the Tranche B-10 Term Loans having an effective interest cost or weighted average yield (excluding any arrangement or commitment fees in connection therewith) that is less than the effective interest rate for or weighted average yield of the Tranche B-10 Term Loans, including, without limitation, as may be effected through any amendment to this Agreement relating to the interest rate for, or weighted average yield of, the Tranche B-10 Term Loans; provided that such prepayment premium shall not be payable if the prepayment or refinancing is made in connection with a Change of Control.

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(a)        The Administrative Agent shall have received executed counterparts hereof (which may include facsimile or other electronic transmission of a signed signature page to this Agreement) from the Borrower, the Tranche B-10 Funding Loan Lender, each Tranche B-10 Converting Loan Lender and the Administrative Agent;

(b)        The Administrative Agent shall have received from the Borrower an opinion of counsel from Simpson Thacher & Bartlett LLP reasonably acceptable to the Administrative Agent covering such matters as are required pursuant to Section 2.14(a) of the Credit Agreement;

(c)        The Administrative Agent shall have received a completed “Life-of-Loan” Federal Emergency Management Agency standard flood hazard determination with respect to each improved Mortgaged Property (together with a notice about special flood hazard area status and flood disaster assistance duly executed by the applicable Credit Party relating thereto) and, with respect to any Mortgaged Property on which any “building” (as defined in the Flood Insurance Laws) is located in a special flood hazard area, evidence of flood insurance as and to the extent required under Section 9.3 of the Credit Agreement;

(d)        The Administrative Agent shall have received an officer’s certificate of the Borrower setting forth the calculations (in reasonable detail) demonstrating compliance with (i) the financial test described in Section 10.8 of the Credit Agreement and (ii) the ratio set forth in the definition of “Ratio First Lien Indebtedness” in the Credit Agreement; and

(e)        The Administrative Agent shall have received a written notice of prepayment on the Tranche B-10 Effective Date of all Tranche B-8 Term Loans (other than the Converted Tranche B-8 Term Loans).

Written or e-mail confirmation from local counsel in the jurisdiction in which the Mortgaged Property is located substantially to the effect that: (i) the recording of the existing Mortgage (and any related fixture filing) is the only filing or record-

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ing necessary to give constructive notice to third parties of the lien created by such Mortgage as security for the Obligations, including the Obligations evidenced by this Agreement and the other documents executed in connection herewith, for the benefit of the Secured Parties, and (ii) no other documents, instruments, filings, recordings, re-recordings, re-filings or other actions, including, without limitation, the payment of any mortgage recording taxes or similar taxes are necessary or appropriate under applicable law in order to maintain the continued enforceability, validity or priority of the lien created by such Mortgage as security for the Obligations, including the Obligations evidenced by this Agreement and the other documents executed in connection herewith, for the benefit of the Secured Parties, unless any such mortgage recording taxes are payable in connection with the transactions contemplated by this Agreement, in which case such written confirmation shall so state; or, for any Mortgage recorded in a jurisdiction in which local counsel is unable to provide the foregoing written or email confirmation, with respect to such Mortgage, the deliverables listed in Section 10(b) below.

(a)        Each Tranche B-10 Loan Lender (x) represents and warrants, as of the date such Person became a Tranche B-10 Loan Lender party hereto, to, and (y) covenants, from the date such Person became a Tranche B-10 Loan Lender party hereto to the date such Person ceases being a Tranche B-10 Loan Lender party hereto, for the benefit of, the Administrative Agent and each other Lead Arranger and their respective Affiliates, and not, for the avoidance of doubt, to

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or for the benefit of the Borrower or any other Credit Party, that at least one of the following is and will be true:

(b)        In addition, unless sub-clause (i) in the immediately preceding clause (a) is true with respect to a Tranche B-10 Loan Lender or such Tranche B-10 Loan Lender has not provided another representation, warranty and covenant as provided in sub-clause (iv) in the immediately preceding clause (a), such Tranche B-10 Loan Lender further (x) represents and warrants, as of the date such Person became a Tranche B-10 Loan Lender party hereto, to, and (y) covenants, from the date such Person became a Tranche B-10 Loan Lender party hereto to the date such Person ceases being a Tranche B-10 Loan Lender party hereto, for the benefit of, the Administra-

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tive Agent and each other Lead Arranger and their respective Affiliates, and not, for the avoidance of doubt, to or for the benefit of the Borrower or any other Credit Party, that:

(c)        The Administrative Agent and each other Lead Arranger hereby informs the Tranche B-10 Loan Lenders that each such Person is not undertaking to provide impartial investment advice, or to give advice in a fiduciary capacity, in connection with the transactions contemplated hereby, and that such Person has a financial interest in the transactions contemplated hereby in that such Person or an Affiliate thereof (i) may receive interest or other payments with respect to the Tranche B-10 Term Loans, the Tranche B-10 Term Loan Commitments and this Agreement, (ii) may recognize a gain if it extended the Tranche B-10 Term Loans or the

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Tranche B-10 Term Loan Commitments for an amount less than the amount being paid for an interest in the Tranche B-10 Term Loans or the Tranche B-10 Term Loan Commitments by such Tranche B-10 Loan Lender or (iii) may receive fees or other payments in connection with the transactions contemplated hereby, the Credit Documents or otherwise, including structuring fees, commitment fees, arrangement fees, facility fees, upfront fees, underwriting fees, ticking fees, agency fees, administrative agent or collateral agent fees, utilization fees, minimum usage fees, letter of credit fees, fronting fees, deal-away or alternate transaction fees, amendment fees, processing fees, term out premiums, banker’s acceptance fees, breakage or other early termination fees or fees similar to the foregoing.

For purposes of this section, the following definitions apply to each of the capitalized terms below:

“Benefit Plan” means any of (a) an “employee benefit plan” (as defined in ERISA) that is subject to Title I of ERISA, (b) a “plan” as defined in Section 4975 of the Code or (c) any Person whose assets include (for purposes of ERISA Section 3(42) or otherwise for purposes of Title I of ERISA or Section 4975 of the Code) the assets of any such “employee benefit plan” or “plan”.

“PTE” means a prohibited transaction class exemption issued by the U.S. Department of Labor, as any such exemption may be amended from time to time.

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[Remainder of page intentionally left blank. Signature pages follow.]

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IN WITNESS WHEREOF, each of the undersigned has caused its duly authorized officer to execute and deliver this Agreement as of the date set forth above.

[Signature Page to Tranche B-10 Joinder Agreement]

SCHEDULE I

[HCA - Signature Page to Tranche B-10 Joinder Agreement]

[ADDITIONAL LENDER SIGNATURES OMITTED]