<?xml version=“1.0” encoding=“UTF-8”?> <Coverage xmlns=“hl7.org/fhir”>
<id value="SP1234"/> <meta> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> <code value="HTEST"/> <display value="test health data"/> </security> </meta> <identifier> <system value="http://hospitalx.com/selfpayagreement"/> <value value="SP12345678"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-selfpay"/> <code value="pay"/> <display value="PAY"/> </coding> </type> <subscriber> <reference value="Patient/5"/> </subscriber> <beneficiary> <reference value="Patient/5"/> </beneficiary> <relationship> <coding> <code value="self"/> </coding> </relationship> <period> <end value="2012-03-17"/> </period> <payor> <reference value="Patient/5"/> </payor>
</Coverage>