H2O IAD Submission - H2OIADSubmission

Member Name *

Member DOB *

AHCCCS ID *

Provider *

Submitter Name *

Submitter Email *

IAD Type *

Select the appropriate IAD type from the dropdown list. PLEASE NOTE: If Sentinel Event is selected, you MUST call and notify Solari Provider Support as soon as possible at 480-935-4362.

In addition, if there is an imminent safety concern, please ensure member safety first by contacting emergency services or other appropriate resources as needed.

For additional explanation around IADs, please reference AHCCCS Policy AMPM 961 .

IAD Type Category *

IAD PDF Attachment * At least one IAD PDF attachment is required. Only PDF files are allowed.