<?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>