Clause 8.5.1 of the Agreement shall be deleted in its entirety and replaced with the following:

Clause 8.1 (Mandatory prepayment – illegality), Clause 8.2 (Mandatory prepayment – change of control), sub-clause 8.3.3 of Clause 8.3 (Voluntary prepayment) or Clause 32 (Pro rata sharing);

[Schedule 8.17] hereto sets forth a complete list of all “business associate agreements” (as such term is defined in HIPAA) that any Borrower or Guarantor has entered into with any person as of the date of Amendment No. 4.

[Schedule 8.18] hereto sets forth an accurate, complete and current list of all participation agreements of any Borrower or Guarantor with health maintenance organizations, insurance programs, preferred provider organizations and other Third Party Payors and all such agreements are in full force and effect and no material default exists thereunder.

[Section 8.1] “Administration” is hereby amended to read in full as follows:

[Schedule 8.1] to the Agreement shall be deleted in its entirety and replaced with the amended [Schedule 8.1] attached to this Amendment.

[Section 8.2(a)] of the Purchase Agreement is hereby amended to insert the following additional defined terms into such Section in alphabetical order:

[Section 8.4] is hereby added:

[Section 8.13] of the Agreement shall be amended as follows:

[Section 8.3.3] of the Project Statement is revised to add “(except as provided below)” after “non-sublicensable”.

[Section 8.3.3.4] is revised to read as follows:

[Section 8.06(d)] of the Credit Agreement is hereby amended and restated in its entirety as follows:

[Article 8.3.2] is deleted in its entirety and replaced with the following one:

SAVINGS CLAUSE. Save and except as hereinabove expressly amended, the Plan Statement shall continue in full force and effect.

Clause 2.2 of the Agreement shall be deleted in its entirety and replaced with the following:

Clause 6.5 of the Agreement shall be deleted in its entirety and replaced with the following:

Savings Clause. If at any time the interest rate set forth in this Note exceeds the maximum interest rate allowable under applicable law, the interest rate shall be deemed to be such maximum interest rate allowable under applicable law.