Self Payment Example (id = "SP1234")

<?xml version="1.0" encoding="UTF-8"?>

<Coverage xmlns="http://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"/> 
  <kind value="self-pay"/> 
  <paymentBy> 
    <party> 
      <reference value="Patient/5"/> 
    </party> 
  </paymentBy> 
  <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> 
</Coverage>