Hospital and Health Care Finance

As part of our Lending and Commercial Services practice group, Frost Brown Todd’s Hospital and Health Care Finance team provides exceptional legal services to borrowers, lenders and other capital providers in the health care industry. In a challenging economy and tight credit market, our understanding of the unique legal issues that face our clients in any complex financing allows us to provide value in every transaction.  Our goal is to be an indispensable and valued advisor in each transaction we negotiate and document.

Our commercial and public finance lawyers also advise hospitals and health care providers, manufacturers, service companies, retailers, distributors and other clients on a broad range of commercial contracting matters, including purchasing, leasing and licensing issues.  We can assist with effectively and efficiently planning, structuring and documenting your finance transactions — whether typical bond issues or sophisticated outsourcing arrangements.

Bond and Underwriter's Counsel

Our lawyers act as bond counsel throughout the United States, representing state and local governments and also as underwriter's counsel, financial advisor's counsel, counsel to governmental issuers, counsel to developers, letter of credit bank counsel and counsel to trustees on public finance transactions. We assist investment bankers in providing creative, cost-effective financing mechanisms for taxable and tax-exempt financing. We have worked with virtually every major national, regional and local banking firm on numerous multimillion dollar projects for health care providers. Over the past years, we have acted as bond counsel or underwriter's counsel in bond issues in Ohio, Kentucky, Indiana, Tennessee, Texas, Oklahoma, Arkansas, Alabama, Missouri, Illinois, Wisconsin, Georgia, South Carolina, Florida, Pennsylvania and Maryland.

Our public finance attorneys are experienced in all types of public, structured and project finance, including health care finance, non-profit and 501(c)(3) finance, economic development and infrastructure finance.

Relevant Experience in Health Care Industry Bond Financing Projects

For health care financings, we serve as borrower’s counsel, bond counsel, underwriter's counsel and hospital counsel in Kentucky, Ohio, Indiana, and Tennessee. Since 2005, Frost Brown Todd has served as borrower’s counsel for more than $2 billion of bond issues in the health care industry. We have experience working closely with bond counsel, bank counsel and underwriter’s counsel to successfully negotiate and close fixed rate bond transactions, draw down bond transactions, letter of credit backed bond financings, and direct placement transactions. We also have represented health care companies with tender offers to redeem outstanding bonds and with interest rate hedging transactions. Some of the specific health care clients our lawyers have represented in bond financing projects include two major hospital systems based in Ohio (and its affiliates in Ohio, Kentucky, Tennessee, Indiana and Pennsylvania); The Cleveland Clinic, Southwest General Health Center (Cleveland area); Methodist Eldercare Services (Columbus area); Jewish Hospital Health Services, Louisville, Kentucky; Ashland Hospital Corporation d/b/a King's Daughters' Hospital, Ashland, Kentucky; Ephraim McDowell Hospital, Danville Kentucky; TJ Samson Hospital, Glasgow, Kentucky; Clark Memorial Hospital, Jeffersonville, Indiana; Caritas Peace Center, Louisville, Kentucky; Sisters of Nazareth Literary and Benevolent Society, Louisville, Kentucky and the Wendell Foster Home in Owensboro, Kentucky.

We also assist clients in developing policies and procedures and reviewing compliance with regulations regarding the use of bond-financed assets and also compliance with financial covenants and conditions in commercial loans.

FBT attorneys have also acted as bond/swap counsel to various health care providers using derivatives and interest rate swaps.

Our commercial lawyers also advise hospitals, health systems and other clients on a broad range of commercial contracting matters, including purchasing, leasing and licensing issues. We can assist with effectively and efficiently planning, structuring and documenting your commercial transactions — whether typical contracts or sophisticated outsourcing arrangements.

Focused within the health care industry, we represent health care systems and health care facilities on a wide variety of public and private financings. We act as borrower's counsel under master indenture and credit agreements, bond counsel for the issue of tax-exempt debt, and as counsel for lenders and borrowers in commercial real estate financing for construction loan and permanent loan transactions. Our clients often require us to be innovative in approaching the financing of health care acquisitions. We also assist clients in developing policies and procedures and reviewing compliance with regulations regarding the use of bond-financed assets, compliance with financial covenants and conditions in commercial loans, and dealing with the unique tax opinions and issues that are part of financings for tax exempt organizations.

Real Estate Finance of Expansions and Development of Health Care Facilities

FBT works actively with our clients in the financing, expansion, development, purchase, sale, leasing and construction of health care facilities. In the past several years, the financing, expansion, and development activities have included hospitals, hospital campuses, on and off campus medical office buildings, development of new hospital campuses, and site assemblage for new health care facilities. Our work has been in all aspects of financings, expansions, site acquisition, negotiations between health care providers and developers on the terms of proposed developments, ground lease arrangements, space lease arrangements, sale of medical office building portfolio, review and negotiation of construction contracts and title work and title insurance. We also regularly coordinate review of financing documentation and arrangements, lease arrangements, title review and environmental review, in connection with the expansion or acquisition of health care facilities.

Our attorneys are recognized by Best Lawyers® in America as well as Chambers USA® Client's Guide and are active members of the leading national real estate industry groups, including Counselors of Real Estate; ABA Real Property, Probate and Trust Division; American College of Real Estate Lawyers; BOMA; International Council of Shopping Centers; NAIOP; Urban Land Institute as well as numerous state and local organizations in our region.

Practice Highlights

FBT’s attorneys have served as Bond Counsel, Underwriter’s Counsel, Borrower’s Counsel or Purchaser’s Counsel in the following recent tax-exempt bond issues:

  • $300 million 2012 financing for a major regional hospital’s new patient tower, parking garage, and refunding of prior bonds.
  • $63,045,000 City of Middleburg Heights, Ohio (Southwest General Health Center Project) Hospital Facilities Revenue and Refunding Bonds, Series 2011
  • $4,160,000 County of Putnam, Ohio Adjustable Rate Demand Health Care Facilities Revenue Refunding and Improvement Bonds, Series 2010 (Hilty Memorial Home Project).
  • $30,000,000 County of Franklin, Ohio Health Care Facilities Revenue Bonds, 2010 (Dominican Sisters of Peace Project).
  • $4,880,000 County of Cuyahoga, Ohio Health Care Facilities Revenue Bonds, Series 2010 (Koinonia Homes, Inc. Project).
  • $30,000,000 County of Darke, Ohio Adjustable Rate Demand Health Care Facilities Revenue Bonds, Series 2010 (Wayne Hospital Project).
  • $31,945,000 County of Lucas, Ohio Health Care Facilities Revenue Refunding and Improvement Bonds, Series 2010 (Lutheran Homes Society, Inc. Obligated Group Project).
  • $46,000,000 Cleveland-Cuyahoga County Port Authority Lease Revenue Bonds, Series 2010 (Cleveland Clinic Project) which was a taxable bond backed by a credit tenant lease to The Cleveland Clinic Foundation
  • $20,000,000 County of Franklin, Ohio Health Care Revenue Bonds, Series 2010 (Methodist Eldercare Services) Hospital Facilities Bonds, Series A, B & C 2010
  • $6,195,000 Greene County Port Authority Adult Service Facility Revenue Bonds, Series 2009 (Greene, Inc. Project)(Non-AMT).
  • $30,000,000 County of Montgomery, Ohio Health Care Facilities Revenue Bonds, Series 2009 (Community Blood Center).
  • $19,500,000 City of Middleburg Heights, Ohio (Southwest General Health Center) Hospital Facilities Refinancing Bonds, Series 2009
  • $10,400,000 City of Middleburg Heights, Ohio (Southwest General Health Center) Hospital Facilities Bonds, Series 2009
  • $17,000,000 Southwest General Health Center – 2009 Letter of Credit Renewal
  • $46,865,000 County of Darke, Ohio Adjustable Rate Demand: Health Care Facilities Revenue Bonds, Series 2007 (Wayne Hospital Project).
  • $330,000,000 tax exempt bond issue in which insured auction-rate bonds were redeemed and replaced by new fixed-rate tax-exempt debt
  • $146,000,000 tax exempt bond issue in which insured auction-rate bonds were redeemed and replaced by a mixture of new fixed-rate debt and variable rate letter-of-credit back debt
  • $1.3 billion in 14 transactions for a regional health system
  • $875 million in nine other transactions for other health care systems as borrowers’ counsel


We have extensive experience in medical and hospital sites, including:

  • The approximate $500 million Atrium Medical Center hospital construction and tax-exempt bond financing, medical office buildings, and related medical facilities project constructed at the hospital campus in Middletown, Ohio
  • 14 Recent financings for two Cincinnati-based health care system
  • Represented hospital chain on financing and real estate aspects of acquiring major suburban hospital in Cincinnati, an asset purchase involving substantial real estate
  • Represented major hospital chain in financing and real estate work associated with closing 45 parcel assemblage for new hospital facility in Greater Cincinnati, including completion of due diligence, review of title and survey and assistance on development issues
  • Tax-exempt bond financing of $30 million for retirement residences in Hamilton County, which included significant and complex issues in terms of construction “pre-start” and the review of construction costs and lien waivers
  • Medical office buildings at four Ohio hospital campus sites and site reconfiguration for the approximate $25 million campus hospital tax exempt bond financing transactions
  • Letter of credit-backed bond financing of approximately $24 million for the renovation/construction of a senior living facility in Cincinnati
  • The assemblage for a proposed new $22 million hospital and medical campus land assemblage and acquisition project
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