exhibit 4. 1 amended and restated articles of organization of rural hospital acquisition, l. l. c. rural hospital acquisition, l. l. c., an oklahoma limited liability company ( the “ company ” ) formed pursuant to the provisions of the oklahoma limited liability company act, okla. stat. tit. 18, § 2000 et seq. ( the “ act ” ), on april 24, 2007 by filing its original articles of organization, desiring to amend and restate its original articles of organization, does hereby execute the following amended and restated articles of organization for the company : i. amended articles. the original articles of organization of the company are amended as follows : a. article v is hereby deleted in its entirety and replaced with the following : “ the equity ownership of the company will be expressed in term of number of units of the company ( “ units ” ) held by an individual or entity. the units will be of two classes, voting units and non - voting units, with differing rights as provided in the amended and restated operating agreement of the company, dated october 30, 2007 ( the “ operating agreement ” ). the authorization or issuance of any new units will require approval by holders of seventy - five percent ( 75 % ) of the outstanding voting units of the company by vote, written consent, or other method approved in the operating agreement. ” b. the following article vi is hereby added : “ except and to the extent otherwise provided in the operating agreement, the company is to be manager - managed by a board of managers ( the “ managers ” ). except and to the extent otherwise provided in the operating agreement, the board of managers will consist of : two managers appointed by surgical center acquisition holdings, inc. ( “ scah ” ) or its permitted successors under the operating agreement, two managers appointed by carol schuster or her permitted successors under the operating agreement, and a fifth director mutually agreed upon by scah or its permitted successors under the operating agreement, on the one hand, and carol schuster or her permitted successors under the operating agreement, on the other. the managers will have all authority conferred or set forth in the act and the operating agreement, provided, however, that the following actions shall require the approval of 80 % of the managers : 1. divesting and / or selling any assets greater than $ 25, 000 in value ; 2. hiring and / or terminating any company executives ; 3. selling