Silver Access Monthly Payment Plan

IMPORTANT: DO NOT SUBMIT PAYMENT TO SILVER ACCESS FOR YOUR FIRST INSURANCE PREMIUM!

YOU MUST MAKE YOUR FIRST PREMIUM PAYMENT DIRECTLY TO YOUR INSURANCE COMPANY!

Your monthly payment will be automatically charged to the card that is provided below on the same day as the first payment submission every month.

If for any reason your monthly payment is declined, our system will grant a free 5 day grace period. On the 5th day, it will attempt to collect the funds. There will not be any late fee applied. Our system will only allow 3 failed attempts after the third your payment plan will be cancelled and you may be at risk of loosing assistance from Silver Access

Refer to your 2024 Member Responsability Acknowledgement Form for payment plan amounts!

If you are unsure of payment amounts, please contact Vanessa Corpus by email vcorpus@accessdupage.org

Payment Form Calc

Enter Monthly Payment Amount*

Monthly Payment(USD for each month)

Total $0.00Total $0.00

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Date

Provide email address to receive a confirmation recipt

Please enter name(s) and DOB(s) of the members this payment is being made on behalf of.*

How is payment being made?

SelfBy PhoneIn-Person at Carol Stream OfficeBy an Agent/Community Partner

If payment is being done by Agent/Community Partner, please add name and organization below:

Please sign to confirm approval of payment plan - If Agent is assisting with payment, please sign on client behalf confirming approval. *

Silver Access Automatic Monthly Payment Plan