---
type: "example"
title: "Coverage Example: coverage-example-selfpay"
resource: "Coverage"
example: "coverage-example-selfpay"
---
# Coverage Example: coverage-example-selfpay

## Narrative

A human-readable rendering of a Self Pay Agreement.

## Example XML



```xml
<?xml version="1.0" encoding="UTF-8"?>
<Coverage xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/coverage.xsd">
	<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>
```