<?xml version=“1.0” encoding=“UTF-8”?><Coverage xmlns=“hl7.org/fhir”>

<id value="SP1234"/>

<text>
   <status value="generated"/>
   <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of a Self Pay Agreement.</div>
 </text>

<identifier>
  <system value="http://hospitalx.com/selfpayagreement"/>
  <value value="SP12345678"/>
</identifier>

<status value="active"/>

<type>
 <coding>
   <system value="http://hl7.org/fhir/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>