Exhibit XII Bed Hold.pdf

Exhibit XII (05/24)

CONGREGATE CARE

BED HOLD AUTHORIZATION

ARIZONA DEPARTMENT OF CHILD SAFETY

Facility Name:

Actual end date of the bed hold:

Contractor

Actual start date of the bed hold:

Child’s Name: Date of Request:Child’s PID:

Number of days requested:

Client Information

AWOL: Confirm calls to Hotline and PD were made

Hospitalization

I am requesting that a bed hold be established for the above child under the above conditions.

NOTE: Completed forms can be submiteed to BedHold@azdcs.gov or via the submit button

Note: Statewide Placement Program Manager can approve up to 7 days of bed hold. Beds can be held for up to 14 days with the Statewide Placement Program Administrator’s signature.

Reason for request:

Extended Visit (waiting for CPC)

Detention

Other [please explain]:

Contractor Signature

Statewide Placement PM/PA

Date

Date

Signatures