{

"resourceType": "Coverage",
"id": "SP1234",
"identifier": [
  {
    "system": "http://hospitalx.com/selfpayagreement",
    "value": "SP12345678"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/coverage-selfpay",
      "code": "pay",
      "display": "PAY"
    }
  ]
},
"subscriber": {
  "reference": "Patient/5"
},
"beneficiary": {
  "reference": "Patient/5"
},
"relationship": {
  "coding": [
    {
      "code": "self"
    }
  ]
},
"period": {
  "end": "2012-03-17"
},
"payor": [
  {
    "reference": "Patient/5"
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}