Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form from the Arizona Department of Child Safety (DCS). The form is designed for contractors and facilities providing congregate care services to request a bed hold for a child under specific circumstances, such as AWOL, detention, extended visit, hospitalization, or other reasons. The form requires detailed information about the child, including name, personal identification number (PID), and the requested bed hold duration.

The form allows for bed holds to be approved by the Statewide Placement Program Manager for up to 7 days, with the potential for extension to 14 days if approved by the Statewide Placement Program Administrator. The contractor must provide the reason for the bed hold request and can submit the completed form via email to BedHold@azdcs.gov or through a submit button. The document includes signature lines for the contractor and the Statewide Placement Program Manager/Administrator to authorize the bed hold, ensuring proper documentation and approval of the child's placement status.