Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form issued by 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. The form allows for bed holds due to reasons such as AWOL status, detention, extended visits, hospitalization, or other situations.

The form provides a structured process for requesting bed holds, with the Statewide Placement Program Manager able to approve up to 7 days and the Statewide Placement Program Administrator authorized to approve up to 14 days. The document includes fields for capturing critical information such as the child's name, Personal Identification (PID) number, contractor details, facility name, actual start and end dates of the bed hold, and the specific reason for the request. Completed forms can be submitted electronically to BedHold@azdcs.gov, with signature lines for both the contractor and the Statewide Placement Program Manager/Administrator.