New MB Advocate Case Request McGohan Brabender - Submit a case Group Name Group ID Member DOB Member Address: Member First Name Member Last Name Member ID * Member ID or SSN is required. Member SSN Patient is the same as Member Patient Name (First, Last): Patient DOB: Contact is the same as Patient Contact is the same as Member Contact Name: Contact Phone #: Contact E-Mail: Date of Service: Provider Information: RX Info (include all relevant information, including dosage, qty): If applicable. Pharmacy Information (Name, phone number): If applicable. Detailed Issue Explanation (additional patients, providers, service dates, if applicable; physician info): If applicable. Additional File Attachments (50Mb Max Total):
