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 care services to document and request approval to hold a bed for a child who is temporarily absent from a care facility due to various circumstances such as being Absent Without Leave (AWOL), detention, hospitalization, or extended visits.

The form allows contractors to request bed holds for up to 7 days with approval from the Statewide Placement Program Manager, or up to 14 days with additional authorization from the Statewide Placement Program Administrator. The document requires detailed information about the child, including name, Personal Identification (PID) number, and the specific reason for the bed hold. Completed forms can be submitted electronically to BedHold@azdcs.gov, with signature approval required from both the contractor and the Statewide Placement Program Manager or Administrator.