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 providing congregate care services to request a temporary hold on a child's bed placement under specific circumstances. The form allows for bed holds due to reasons such as AWOL (absence without leave), detention, extended visits, hospitalization, or other specified conditions.

The form provides a structured process for bed hold requests, with key provisions including the ability of the Statewide Placement Program Manager to approve up to 7 days of bed hold, and the Statewide Placement Program Administrator authorized to approve bed holds up to 14 days. Contractors must complete the form with details about the child, including name, personal identification number (PID), facility name, and specific reason for the bed hold. Completed forms can be submitted electronically to BedHold@azdcs.gov. The document includes signature lines for the contractor and the Statewide Placement Program Manager/Administrator to validate the request.