Name: Berlanco Insurance Agency
Address: 1160 S. State Street, Ephrata, PA, 17522, US
Telephone: (717) 859-1922

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Address*
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List of Prescription Medications (please list the complete name of medication as shown on your prescription including dosage and quantity per day. Example: Metoprolol Succinate ER, 50 MG, 1 x daily) If no current medications type “none”.*
Preferred Pharmacy (list the pharmacy name you use to obtain your prescriptions. If you prefer mail order, please provide a pharmacy name in the event you would need to go to a pharmacy)*
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Current Prescription Plan (please provide name of plan and premium if known – i.e. Wellcare Value Script - $12.90. If unsure, type “unknown”)*
Would you also like us to review your Medicare Advantage Plan? Note: Medicare Supplements can be reviewed any time of the year.*
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