Sanford Health and Marshfield Clinic Health System officially signed a $10 billion merger agreement, according to a joint announcement made on Wednesday. The agreement follows their initial disclosure of merger plans in July.

The two health systems said the merger would enhance access to high-quality care for residents in the rural Midwest. Upon completion, the combined entity is expected to generate approximately $10 billion in annual revenue.

Sanford Health, the largest rural health system in the U.S., operates 45 hospitals, 211 clinics, and over 160 senior living centers. Headquartered in Sioux Falls, South Dakota, Sanford employs 2,900 physicians and advanced practice providers.

Marshfield Clinic Health System, based in Wisconsin, oversees 60 clinics, 11 hospitals, and a children’s hospital, with a workforce of more than 1,700 providers. Both systems also manage their own health plans, which together would serve over 425,000 members once the merger is finalized.