Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form issued by the Arizona Department of Child Safety. It 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 various reasons such as AWOL (absent without leave), detention, extended visits, hospitalization, or other situations.

The form enables the Statewide Placement Program Manager to approve up to 7 days of bed hold, with the Statewide Placement Program Administrator able to extend the hold to a maximum of 14 days. Contractors must complete the form with details including the child's name, Personal Identification (PID) number, facility name, and specific reason for the bed hold request. The form can be submitted electronically to BedHold@azdcs.gov, and requires signatures from the contractor and the Statewide Placement Program Manager or Administrator to validate the bed hold request.