{
  "payerId": "BCBS001",
  "patientLastName": "Smith",
  "patientFirstName": "Jane",
  "patientBirthDate": "1980-01-15",
  "fromDate": "2025-01-01",
  "toDate": "2025-12-31",
  "providerLastName": "Johnson",
  "patientSameAsSubscriber": true
}