Douple Agency | Insurance Agency Ephrata PA Lancaster Lititz Medicare

Thank you for choosing to use our expedited review process so we can help you navigate your medicare choices this year.  Please take a few minutes to provide us your updated information. Please complete one separate form for each individual. 

Disclaimer: Under Medicare laws, you are not required to provide any personal health care information. As a current customer, the information you are voluntarily providing cannot be used to determine eligibility. This information will solely be used to verify that your medications are covered on your plan’s drug formulary list. For more information regarding your Medicare rights, please click here.





Your Name (please provide first AND last name)

Your Address

Email Address

Phone Number

List of Medications (please list name of drug, dosage, quantity – i.e Generic Lipitor, 10 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)

Do you ever use mail order?
YesNo

Current Prescription Plan (please provide name of plan and premium if known – i.e. Humana – $7.00. If unsure, leave blank)

Is there anything else you would like us to know, or to take into consideration?

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